DRAFT Strategic Service Delivery
Plan for out of hospital care
delivery
NHS WEST LONDON CCG
Edition: Governing Body draft
Date: 13-03-14
Approved
Page 1
Version Control
Document Details
Programme
Out of Hospital Hubs Outline Business Case
Status / Version
V1.3
Document Approval
Criteria
Name & Role
Signature
Date
Author
Author
Reviewer
Approver
Document Summary
This is the Strategic Services Delivery Plan (SSDP) for West London CCG. It is a predecessor to the
Outline Business Case for Out of Hospital Hubs in NHS NWL.
Version Control Details
Version
Status
Date
Author
Description of Change(s)
1.1
1st
Draft
21.02.13
SARAH MCDONNELL
Draft version
1.2
2nd draft
03-03-14
SARAH MCDONNELL
Draft amendments
1.3
3rd Draft
13-03-14
Kemi Ayorinde
Draft version
Page 2
Purpose of the SSDP
This Strategic Service Delivery Plan (SSDP) is the next step in West London CCG’s (WL
CCG) response to the unprecedented challenges it faces to ensure a sustainable and
effective healthcare system. It builds on the previously published WL CCG Out of Hospital
Delivery Strategy. It details West London CCG’s new model of out of hospital care and
outlines the implications of this model, focusing in particular on the implications for estates,
workforce and informatics.
Part 1 makes clear the scale of the challenge in West London and contextualises the
CCGs response. Part 1 of the SSDP outlines the local context and the wider (regional and
national) strategic context. These directly influence the likely increase of demand in out of
hospital settings and the local response to this (the proposed model of out of hospital care
presented in chapter 4).
Part 2 describes the infrastructure implications – focusing in detail on the estate
implications - arising from the proposed new model of out of hospital care.
Accommodating an increased volume of activity in primary and community settings and
ensuring the primary and community care estate meets quality standards and enables new
ways of working is a major task. It is likely to require major change in three main areas workforce, informatics and estate. Part 2 presents a summary of the implications for each of
these areas but focuses most heavily on the implications for the estate in West London which
will need to be of sufficient quality and have sufficient capacity to successfully deliver the new
model of out of hospital care.
In Part 2 we examine the estimated service activity levels for out of hospital care and the
resulting space requirements. This SSDP identifies how we might transform our existing
estate to ensure its effective use and where we might need to invest in our estate. We focus
in particular on the additional space requirements and the case for the development of
locality-based hubs. We briefly outline the plans being developed for the GP estate before
looking in detail at the associated idea of hubs. Hubs are a key setting for the delivery of out
of hospital services in WL CCG’s new model of care. They will help localise and integrate the
most common services people need for everyday illnesses and provide the additional
capacity needed in the primary and community sector to enable a shift away from the acute
sector.
We present the methodology used in the identification of potential hub sites and the
evaluation of the site options. Activity and estates modelling supports the development of
conclusions about the way in which we might use and upgrade our existing estate, the
additional space required to support hub activity. As part of the SSDP process, we evaluate a
list of potential sites within the CCG that could deliver hub services and evaluate these sites
against a set of threshold and prioritisation criteria. By the end of this process we will have a
detailed understanding of the pipeline for the proposed hub estate. These will be carried
forward to Outline Business Case (OBC) stage for further evaluation.
Page 3
Part 1
Page 4
1. An introduction to the NHS in West London
West London CCG (WL CCG) covers a small but densely populated area in west London.
WL CCG commissions services on behalf of approximately 230,000 patients living
predominantly in the Royal Borough of Kensington and Chelsea and the North of
Westminster (Queen’s Park and Paddington)1 as well as those visiting and working in the
area. The population is highly mobile making the commissioning and delivery of planned,
proactive, coordinated care more of a challenge. The local NHS delivers primary, community
and acute care commissioned by NHS England and West London CCG.
Data from the Royal Borough of Kensington and Chelsea (RBKC) Joint Strategic Needs
Assessment (JSNA) shows the population is unusual as it has a large proportion of older
working age residents (the 8th highest proportion of older working age residents and 12th
highest of retirement age) and 15.4% of children (which is the second smallest in London).
It also has high levels of international migration with 50% of residents born abroad (2011
Census) with only 28% saying their main language in English. The CCG is also culturally
diverse: four in ten of the population is classify themselves as ‘white British’, about a third of
the population classify themselves as from ‘other white’ backgrounds (31%), with American,
French, Italian and Spanish communities among the more prominent. Nearly a third (29%) of
the population is from a Black and minority ethnic group, up from 21% in 20012.
The local housing stock is primarily made up of flats – 83% compared to half in London. This
means households in the area have limited outdoor space and access can be difficult for
those with mobility issues. 34% of residents live in private rented housing – the 4th highest
proportion in London. Only 37% are owner occupiers – the 10th lowest in London. One
quarter (25%) of resident live in social housing - similar to London averages. Kensington and
Chelsea has the highest percentage of one person households in the country (47%). One in
ten households is a lone pensioner household with almost half of older people (43%) in the
borough live alone. This puts them at increased risk of social isolation and reducing the
likelihood of them being able to self-care. Pressure on social housing stock and property
prices in London has also resulted in overcrowding3.
The area is also economically diverse with rich and poor living side by side particularly in the
north of the borough4. Consequently, West London CCG commissions services for some of
the most deprived wards in London, as well as some of the most affluent. Our northern wards
are generally more deprived, with more residents living in social housing, poorer lifestyles
and higher rates of chronic disease5. 28% of the CCG (which includes the St. Charles ward)
fall into the 20% most deprived wards nationally and four wards (St Charles - 130, Notting
Barns, Queens Park and Harrow Road) fall into the 20% highest premature death rates
nationwide. In contrast, the Borough of Kensington and Chelsea was ranked the 103rd most
deprived in the country according to the index of multiple deprivation 2010.
The north of the area covered by West London CCG has correspondingly worse health
outcomes. The wards falling into the worst 20% in London for self-reported bad/very bad
health, self-reported limiting long-term illness (LLTI) and self-reported working age LLTI are
Golborne, St Charles, Notting Barns and Cremorne. The area also has worse than London
and England rates of injuries due to falls in people aged 65 and over and emergency
readmissions within 30 days of discharge from hospital.6 Life expectancy is also different in
1
2
3
West London CCG Commissioning Intentions 2013/14
Royal Borough of Kensington an Chelsea JSNA Highlights Report 2013
Ibid
4
Ibid
5
St Charles Centre for Health and Wellbeing Strategic Outline Case July 2013
6
Ibid
Page 5
3
Sttrategic Overview
O
3.1
Stt Charles, Northern Hub
b – Strategicc Need
Section 3.6.5 of the Wesst London CCG Commissioninng Intentions deetails the develo
opment of 2 neew provider hubbs for the Westt
the mortality rates across the CCG with residents people in the most northerly wards twice
London locality – St Chaarles, north of the
t borough, annd Earl’s Courtt, south of the borough. The ddevelopment of
o each hub (ass
as
likely to die before age
75 as those in the South Kensington. Heart
disease, stroke, cancer
stated in thhe CCG’s commissioning intentions) will co-oordinate providers ‘to deliver integrated care and provide a range of out off
and
respiratory diseases contribute most to the life expectancy gap between rich and poor.
hospital seervices in line with
the health needs
n
of the loccal population.’
Figure
1 belowwshows
the
deprivation
(left) and mortality rates (right) mapped by council
ward.
In reviewinng the CCG’s leevels of deprivaation and undeer 75 mortality rates
r
(as taken from the West London CCG Commissioning
C
g
Intentions)) it is evidentt that a local solution is reequired to ad
ddress the inc
creasing healtth inequalitiess between thee
Reducing
health inequalities is a real challenge for our local healthf system.
It is thus evident
northern and southern regions, speccifically the heealth needs off the northern locality (detaailed further in figure
1). Both
h
that
a
local
solution
is
required
to
address
the
increasing
health
inequalities
that exist across
Shaping a Healthier Futture and the Out
O of Hospitall Strategy prop
pose 2 new hubs for West Loondon - 1 in th
he North of thee
7.
the
CCG
Borough and 1 in the South
S
of the Borough, in lig ht of the contrasting health needs for Weest London thee clinical casee
for a Soutthern Hub, maay require review. Figure 1 b elow identifies the index of de
eprivation for W
West London (m
map on left) andd
the under 75 mortality rattes for the West London localitty from 2006-20010 (map on rig
ght);
Figure 1: Deprivation (left) and mortality rates (right) mapped by council ward
Figure 1 Wesst London Index off Deprivation (Map Left)
L and Under 755 Mortality Rates (M
Map Right)
The
population
inhealth
West
London
is mostly
densely
concentrated
and frequently exceeds
Both maps
s identify the staark
inequalities
betweeCCG
n the northern
and southern
parts of the CCG
G area. 28% of the CCG
the
upper
quintile
range
(16,067
–
218,551
people
per
square
mile)
in
most areas. The
(which includes the St. Charles ward) fall into the 20% most deprived wards nationally and four ward
rds (St Charles - 130, Notting
CCG’s
population
is
served
by
about
54
GP
practices.
Practices
in
the
north of the CCG
Barns, Queens Park and Harrow Road) fall into the 20%
% highest prem
mature death rattes nationwide. Those living inn St Charles,
area
in
particular,
generally
commission
services
from
the
same
acute
and
community health
Queen’s P
Park or Harrow Road wards aree more than tw
wice as likely to die before the age
a of 75, than those in the Soouth
providers
as their counterparts in the north
ofneeds
ourfoorneighbouring
CCG
(Central London CCG)
Kensington area. Therefoore, a local solution that will address the health
h
the northernn wards is requ
uired.
as these patients have similar demographic, cultural and socio-economic characteristics. The
CCG has formed a collaborative with four other neighbouring CCGs (Hammersmith &
Fulham, Central London, Hounslow and Ealing).8.
A significant amount of NHS care of patients in West London is provided outside of the
hospital setting with services provided by a range of providers including GPs
and GP out of
122
hours services, Acute Trusts, Mental Health Trusts, Community providers and third sector
groups. Social Care services are provided by Westminster City Council. Acute providers
include: the Imperial College Healthcare NHS Trust, the Chelsea and Westminster Hospital
NHS Foundation Trust and the University College London Hospitals NHS Foundation Trust.
Other providers include There is also the Central London Community Healthcare NHS Trust
who provide community services, the Central and North West London Mental Health Trust
and the West London Mental Health Trust who provide Mental Health services in the CCG.
The map below shows the locations from which these services are currently delivered.
Figure 2: West London – all estates9
7
8
9
Ibid
St Charles Centre for Health and Wellbeing Strategic Outline Case July 2013
See appendix 1 for labelled list of sites
Page 6
Page 7
2. The case for change
We must ensure the NHS in West London can effectively service the needs of today’s
local population and ensure the NHS in West London is sustainable and fit to meet future
needs. This will mean addressing significant demographic and non-demographic pressures
that exist on the system. The specific drivers of change are described below.
2.1 Demographic and non-demographic drivers of change in West
London
2.1.1 Growing health challenges
Longer life expectancy, chronic disease and inconsistencies in patient experience, alongside
an increasingly expensive treatments and technologies, are making our current model of
healthcare unsustainable. The continued growth of our over 65 year old population means
that, by 2015, the prevalence of dementia will rise by a third and the number of people
surviving a stroke will increase by a quarter. We must find ways of addressing these health
inequalities and long term conditions.
About 1 in 5 patients in the CCG area is living with at least one long-term condition. Of these,
more than 25% have two or more such long-term conditions. High prevalence and early
death from these diseases are much more common in the northern wards where the greatest
level of deprivation in the CCG exists. Chronic disease prevalence is influenced by a set of
preventable risk factors, including smoking, alcohol, poor diet and lack of exercise. More than
1 in 6 people in the area still smoke – this could be mitigated with improved access to health
information and care. Heart disease, stroke, cancer and respiratory diseases contribute most
to the gap in life expectancy between rich and poor10.
Mental health is also an issue with a very high prevalence of severe and enduring mental
illness. Approximately 3200 of the patients known to primary care have a severe and
enduring mental health problem, putting the West London CCG area within the top five
prevalence rates of areas nationally. Kensington and Chelsea also has the 12th highest rates
of acute sexually transmitted infection (STI) diagnosis in England11.
2.1.2
Increasing demand
The health needs of residents are changing as the general population ages and people live
longer with more chronic and lifestyle-related diseases. In 2030, women aged 65 in West
London will live for four years with a disability, compared to three years in 2010. The
number of stroke survivors will rise by 26% in the next 15 years. Mental health is the
biggest burden in terms of reduced quality of life years 12.
2.1.3
Financial constraints
West London CCG faces the continued financial challenge to deliver more with less
resource. Our healthcare system is becoming financially unsustainable as demand and costs
continue to rise. In addition, we must make our contribution to the NHS efficiency savings
required by Government. In West London we must find a sustainable way of securing a QIPP
saving of £25.4m by 2017/18, and delivering 24/7 services for our patients within a low
growth context. We need a model of care that can deliver high quality services in the most
suitable, cost-efficient settings13.
10
St Charles Centre for Health and Wellbeing Strategic Outline Case July 2013
11
Ibid
12
West London CCG Better Care Closer to Home
13
West London CCG Out of Hospital Delivery Strategy 2013
Page 8
2.1.4
Variability in access and quality of care
Whilst people’s experience of GPs in West London is positive, more must be done to improve
people’s experience of primary care access. Although 91% of West London patients have
confidence in their GP, only 16% of patients feel they have access to another health
professional other than their GP, and only 6% believe they can access a walk-in service14.
Patients across London also report feeling less able to book appointments or order repeat
prescriptions online, or make next day appointments with their GP.
2.1 5 Poor quality estate
Improving the quality of the primary care estate so that it is an acceptable standard for
healthcare provision is essential to delivering an integrated model of care that provides care
of a high standard to patients. Estate quality will also be a major focus for the Care Quality
Commission over the next few years. It is their intention that by 2016, every GP practice will
have been inspected and its quality rated. In some cases, the quality of estate will have to be
improved to avoid closure. The shift of activity out of hospital and into a range of primary care
and community settings puts additional pressure on the existing estate, as these will have to
meet these quality standards as well as having the space requirements to meet the activity
demands of the future. 7% of the existing primary care estate in West London has been
assessed as unacceptable and either not capable of being improved or requiring major
redevelopment (DDA ratings of CX) with approximately 77% being graded as a C (not
satisfactory) or D (unacceptable),
2.1.5
Patient expectations and feedback
Feedback from West London patients tells us they want local health and care services to
deliver better quality, more accessible and more co-ordinated healthcare in and out of
hospital. Their feedback directly informs our development of plans for out of hospital care.
Our patients tell us they would like:

Effective sign-posting to treatment and services in the community to avoid
patients from being confused when discharged. Our patients are not always made
aware about the best alternatives for treatment or follow up available to them or even
what is in their own care plan.

Timely referrals to specialist care when needed, to ensure conditions do not
deteriorate while patients wait.

Better knowledge and treatment of mental health problems in primary care15.
Engagement of patients across NW London16 has identified ten priorities; 7 out of 10 related
to access17. These priorities can be grouped across three domains:



Improved quality and reduced variation - having access to appropriate
appointment times, skilled GPs, compassionate staff and consistently good services;
Better integrated services - smooth and co-ordinated pathways, with access to
specialists and a good range of tests and services. A continuing, trusted relationship
with their registered GP was at the centre of this, and;
Flexible access - Patients expect to easily reach someone on the phone and get an
emergency appointment when they need one.
14
North West London General Practice Priorities, February 2013
West London CCG Out of Hospital Delivery Strategy 2013
16
Survey of 1,040 patients
17
Ref Challenge Fund
15
Page 9
These reflect and align with the national expectation for better integration and co-ordination
of all care; National Voices (a coalition of health and social care charities in England) has
defined good co-ordinated care from the perspective of the service user as:
“I can plan my care with people who work together to understand me and my carer(s),
allow me control, and bring together services to achieve the outcomes important to
me”
This definition has been adopted by NHS England, Public Health England, Monitor and local
authority bodies and must inform everything we do. The characteristics central to this model
include: patients setting their own goals and outcomes; shared decision-making; effective
transitions between services; good communication across the system; information sharing,
and; improved care planning.
Page 10
3. National and regional responses to these drivers
The ways in which the system should respond to these pressures has already been
considered at national, regional and local levels. All stakeholders are clear that
transformative change is required. WL CCG’s local plans represent a good strategic fit
with associated national and regional responses.
3.1 National response
At the national level, NHS England clearly stated their requirements in A Call to Action18, a
document which calls for substantial change in the way health services are organised and
delivered in order to ensure NHS services remain free at the point of access. The changes to
healthcare required by A Call to Action include:




A greater focus on preventative rather than reactive care
Services matched more closely to individuals’ circumstances (instead of a ‘one size
fits all’ approach)
People better equipped to manage their own health and healthcare (particularly those
with long term conditions)
A reduction in inappropriate admissions to hospital and avoidable re-admissions
(particularly amongst older people)
In A Call to Action, NHS England makes clear that whilst structural change is important and
will be required, structural change alone will be insufficient. In order to meet the extensive
challenges facing the healthcare system, fundamental transformation of the way primary,
secondary and community care is delivered and used, is required at local level.
A Call to Action reflects a range of nationally published evidence, all of which makes clear
that healthcare needs to shift away from reactive, episodic treatment of patients, to
coordinated, patient-centred care. This puts the patient in the centre with services
organised around them. The patient’s GP will operate as the central point in the system
ensuring primary and community services are organised around the patient and delivered as
close to home as possible helping improve both quality and access. This will be the
organising principle for both health and social care in the future.
In addition, the integration of health and social care (both commissioning and provision) is
being driven nationally. In A Call to Action, NHS England attribute rising demand in part to
the effect of poorly joined up care. They note:
New thinking about how to provide integrated services in the future is needed in order to give
individuals the care and support they require in the most efficient and appropriate care
settings, across health and social care, and in a safe timescale19.
We know from existing efforts to integrate health and care services (for example, the national
Integrated Care Pilots) that there are clear benefits to this approach: patients feel more
involved in their care, professionals are able to develop a more sophisticated understanding
of their patients and undertake peer review where appropriate and the local healthcare
system is better able to anticipate and manage demand.
The system will need to be better coordinated and integrated for patients and services users
– particularly those with complex or long term conditions. This will mean a new way of
working for health and social care professionals. All health and care professionals will be
18
The NHS belongs to the people: a call to action, cited http://www.england.nhs.uk/wpcontent/uploads/2013/07/nhs_belongs.pdf
19
Ibid: p8
Page 11
expected to collaborate and work across traditional boundaries. Multi-disciplinary working will
become the new norm, helping smooth patient journeys and prevent escalation of need and
avoidable hospital admissions. Health and social care professionals will work across
localities as part of a network of providers.
CCGs are already organised into localities. Localities represent clusters of the local
population against which the CCG analyses need and commissions services. Within each
locality, GP practices are coming together to form and work as a network. Networks will offer
a blend of localism and scale – they are sufficiently local to ensure GPs and other providers
maintain a link with individual patients and of sufficient scale to ensure we can deliver
sophisticated services to local populations. The networks will be developed so they give
patients access to a range of out of hospital services in convenient settings, providing
patient’s access to local services above and beyond what is currently available in general
practice. Networks will enable GP practices to provide the additional capacity, flexibility,
limited specialisation and economy of scale to deliver the new model of care in a sustainable
way. Networks are taking shape across the country – in many cases they are based on
existing relationships to ensure trust, cooperation and effective transformation.
3.2 Regional response
At the regional level health partners from across North West London have been working
together on the Shaping a Healthier Future (SaHF) programme. Led by clinicians, the
SaHF programme has developed proposals that will improve both primary and emergency
care. Following a significant programme of consultation with patients, carers, members of the
public and professionals across NW London, the SaHF Decision Making Business Case
(DMBC) was signed off. In this document, it was agreed that improving care in NW London
so it displays the characteristics described above means three things – localising,
centralising and integrating. Each one is described in more detail below:

Localising
o Reducing admissions with better local management of care
o Improving support for patients with LTCs and mental health problems
o Improving patient experience and satisfaction
o Improving carer experience

Centralising
o Achieving better clinical outcomes including reduced morbidity and mortality
o Reducing readmissions
o Reducing lengths of stay
o Increasing staff training, skills and job satisfaction

Integrating
o Increased multidisciplinary working – improving coordination
o Improving access to information - leading to better patient care
o Reducing unnecessary investigations and duplication of assessments
o Improving efficiency and pathways
Delivering the clinical vision and required standards laid out in Shaping a Healthier Future,
means services will need to be provided across a range of care settings in NW London. This
will give NW London residents access to better quality care in specialist, major and elective
hospital settings. The range of care settings available to patients and the availability of these
providers is summarised in the diagram below.
Page 12
Figure 3: Shaping a Healthier Future – care settings20
Changes to primary and community care setting as well as acute care settings are being
prepared. In NW London, the integration of health and social care systems is being driven
nationally and the associated ways of working, will be extended to all care pathways as part
of a move to Whole Systems Integrated Care21. Whole Systems Integrated Care will
underpin change across the local healthcare system. Care will be organised around the
patient with local GP practices and other relevant health and care organisations providing
care through local networks. Whole Systems Integrated Care is underpinned by three key
principles:
1. People and their carers and families will be empowered to take control of their
own care and receive the care they need in their own homes or in their local
community. We will work together to promote the long term, sustainable wellbeing of
the whole person.
2. GPs will be at the centre, organising and coordinating people’s care and acting
as the people’s champion, ensuring people receive high quality integrated care
that helps them achieve their own goals. GPs will work with other providers in
integrated networks and will be able to draw upon all the services and resource they
need to meet people’s care goals. Whilst not all care or coordination has to be
delivered by individual GPs, the GP’s patient register will be the organising principle
that guides how care is co-ordinated between agencies.
3. Systems will enable and not hinder the provision of integrated care. The
financial model will pay for people’s health and social care needs on a basis that
rewards outcomes not contacts. Commissioning budgets will also be pooled where
this would be beneficial for the population. To enable seamless delivery, information
about people’s care will be shared with them and, with their permission, across the
organisations that are responsible for providing their care. Leaders will no longer
accept ways of working that are silo-based and do not consider the needs of people
beyond their own part of the pathway of care. Providers will be responsible for taking
joint accountability for achieving a person’s outcomes and goals and will be required
to show how this delivers efficiencies across the system.
20
SaHF 28 November Joint Workforce Workshop
21
NHS North West London
Page 13
In summary we want to move healthcare delivery closer to home, enable GPs to organise
and coordinate care in collaboration with patients and carers. We also want to integrate
health and social care delivery to ensure efficient use of resource and improve service user
outcomes. This will require major change to the way health and care services are organised
and provided. To ensure this can happen, care will have to be organised differently. In the
future localities and networks will become crucial organising principles. This will help us
deliver services to patients which respond to three challenges – the need for urgent care
(same day emergency consultations (including home visits) for those that need it),
convenient care (appointments at a time and place and in a medium convenient to the
patient) and continuity of care (consistent appointments with a named, trusted clinician,
with appointment length tailored to patient need) 22.
As part of the SaHF process, clinical standards for out of hospital care were developed,
consulted upon and revised. These standards are crucial because it is important that all
stakeholders - patients, their carers, commissioners and providers - are clear about what is
expected of out of hospital services. Six standards for out of hospital care were agreed as
part of the Out of Hospital Delivery Strategy. These set the benchmark for the improvement
of care in a consistent manner across the eight CCGs in NW London. These standards were
directly informed by - and explicitly capture - feedback from patients and carers23.
Figure 4: Out of Hospital clinical standards
OOH Standards
Domain
A
Individual
Empowerment
& Self Care
B
Access
convenience and
responsiveness
C
Care planning and
multi-disciplinary
care delivery
D
Information and
communications
E
Population- and
prevention-oriented
F
Safe and high
quality
▪
Individuals will be provided with up-to-date, evidence-based and accessible information to support them in taking personal
responsibility when making decisions about their own health, care and wellbeing
▪
Individuals will have access to telephone advice and triage provided 24 hours a day, seven days a week. As a result of this
triage:
Cases assessed as urgent will be given a timed appointment or visit within 4 hours of the time of calling
For cases assessed as not urgent and that cannot be resolved by phone, individuals will be offered the choice of an
appointment within 24 hours or an appointment to see a GP in their own practice within 48 hours
▪
▪
▪
▪
▪
▪
▪
▪
All individuals who would benefit from a care plan will have one.
Everyone who has a care plan will have a named ‘care coordinator’ who will work with them to coordinate care across health
and social care
GPs will work within multi-disciplinary groups to manage care delivery, incorporating input from primary, community, social
care, mental health and specialists
With the individual’s consent, relevant information will be visible to health and care professionals involved in providing care
Any previous or planned contact with a healthcare professional should be visible to all relevant community health and care
providers
Following admission to hospital, the patient's GP and relevant providers will be actively involved in coordinating an individual’s
discharge plan
▪
The provider has a responsibility to pro-actively support the health and wellness of the local population. This includes
prevention (e.g. immunisation, smoking cessation, healthy living), case-finding (e.g. diabetes, COPD, cancer) and pro-active
identification and support for patients from hard to reach groups
▪
Patients experience high quality, evidence-based care and clinical decisions are informed by peer support and review. Clinical
data are shared to inform quality assurance and improvement
22
Cited from Challenge Fund application
23
Out of Hospital Delivery Strategy West London CCG
Page 14
4 Local response - transforming out of hospital care in
West London
Cumulatively, the challenges outlined above are driving major change to the way we
organise and deliver health and care services in West London. If we are to meet the rising
demands on health and care services, remain financially sustainable, and ensure high quality
accessible services that meet patient expectations, then we will need to make extensive
changes to the way current health and care services are organised and delivered. Significant
change will need to take place locally, driven and reinforced by change (strategic and
operational) at regional and national levels.
The cumulative impact of these drivers of change on West London is shown in the
graph below. This shows how demand on local out of hospital services will change over the
next five years. It shows a significant shift to the delivery of care in out of hospital settings
and what this means. Each of the three drivers of demand in the graph below will contribute
to a rise in the demand for out of hospital care. It is worthwhile to note that this SSDP does
not reflect the corresponding effect (on the acute hospital sector) of bringing services out of
hospital.
Figure 5: Percentage increase in demand for out of hospital care in West London
140
120
12
3
100
9
80
125
60
100
40
20
0
Out of hospital demand
12/13
Demographic pressures
Non-demographic
pressures
Shift in care to OOH
settings
Out of hospital demand
17/18
The cumulative effect of these three factors is an increase in demand for out of
hospital care of approximately one third (25-30%) across the West London CCG area
compared with 2012/13 levels.
This translates into a corresponding increase in required capacity in out of hospital
settings, to manage this increase in activity.
As well as delivering more care, out of hospital providers will be delivering more
effective out of hospital care – care that is patient centred, integrated and coordinated
across networks and localities.
4.1 West London’s new model of out of hospital care
4.1.1 Requirements of the model
Page 15
A simple increase in capacity in traditional primary and community care settings is neither
achievable financially nor adequate to meet requirements for improved quality and reduced
variation. Delivering more of the same will also fail to achieve the objectives for out of
hospital care outlined in chapter 3. There is a significant body of evidence that says a more
radical transformation is needed. West London needs a local model of out of hospital care
which:







Equips people to self-care and self-manage
Improves access and quality and reduces variability
Delivers integrated and coordinated care for individual patients
Integrates and coordinates care across networks and localities
Delivers patient-centred care to better match services to people’s individual
circumstances and improve people’s experience
Reduces waste, overlap and duplication by making the most efficient use of
resources across health and care.
Improves outcomes by delivering the right care, in the right place, at the right time
4.1.2 Vision
WL CCG has outlined the local strategy for transformed out of hospital care in Better Care,
Closer to Home. This takes into account the national, regional and local challenges
impacting the health and care systems in West London and provides a detailed strategy for
how to deliver coordinated, high quality care in the future. It describes how the delivery of
care can be improved so that patients and carers benefit from a better experience and
outcome. The strategy has five main elements to it which, taken together, summarise the
vision for West London:





There will be easy access to high quality, responsive primary care
There will be simplified planned care pathways
There will be rapid response to urgent needs so that fewer patients need to access
hospital emergency care
Providers (social and health) will work together, with the patient at the centre
Patients will spend an appropriate amount of time in hospital when they are
admitted 24
The new model is not just about delivering more care in out of hospital settings. It is also
about delivering care differently as a ‘lift and shift’ of activity away from the acute sector will
not enable us to adequately respond to the pressures on the system.
Achieving this will require significant transformation (redesign and redevelopment) of the
existing health and care system in West London. It will mean changing the way health and
care professionals organise themselves (new roles) and work together (new ways of working
for example multidisciplinary teams) and the training and development of the workforce
more broadly. It will mean better health informatics and effective use of existing and new
systems for data and information sharing. It will mean driving activity out of the acute sector
and delivering more care in out of hospital settings and this will require us to invest in and
develop out of hospital estate. These implications are expanded upon in part 2.
4.1.3 Delivery plans
The Out of Hospital Delivery Strategy develops this new model by further outlining: what
out of hospital services need to be provided locally, the settings in which they will be
available, how West London’s out of hospital provision will deliver what patients want, how
West London’s out of hospital provision will meet rigorous quality standards and what the
local infrastructure (workforce, informatics and estate) will need to look like to deliver the
24
Better Care Closer to Home NHS West London Clinical Commissioning Group 2012 - 2015
Page 16
planned model of care. The Out of Hospital Delivery Strategy also outlines progress already
made as WL CCG work towards this vision. Progress since 2012 includes:





Establishing Putting People First aligned with the Integrated Care Pilot, to deliver a
care planning and case management approach
Restructuring community nursing to support care planning and the delivery of case
management based on need. Community nursing teams to be reconfigured to align
more closely with GP practices
Improving the specification for the Community Independence Service, including
rapid response, to better meet the needs of local patients
Procuring community care pathways such as musculoskeletal and dermatology to
deliver improved community based services across West London
Developing the case for an older person’s consultant to support network-based
delivery of care for older people
Further work will be done as WL CCG continue to work towards a model of out of hospital
care which is accessible, proactive and coordinated and able to offer urgent access,
continuity of access (where relevant) and convenient access. Services will be available to
patients at GP practices, network, locality and borough-wide level.
Accessible
The WL CCG model focuses on interventions in two areas: supporting patients to selfmanage and providing individuals with a simple, convenient point of entry into the out of
hospital system. We expand upon each below.
Ensuring patients can self-manage wherever possible is central to the WL CCG future model
of care. We know many service users want to play a role in the management of their own
care but that the current system does not provide patients with the information, advice and
support they need to self-manage. In the new model of OOH care patients, carers and their
families will be supported to manage their care in a variety of ways:



Patients (and where appropriate their carers) will be equipped with up-to-date
information appropriate to their condition, as well as in relation to their health and
wellbeing (e.g. on smoking cessation, alcohol, diet and exercise).
Trained patient educators will provide this advice, as well as connecting patients to
voluntary sector programmes where they can learn how to self-manage, and get
advice and support from other service users.
We will work with patients to understand how they engage with local services and
make decisions about their care to help us ensure that we design a health and social
care system that meets their needs and behavioural preferences.
Other health professionals such as community pharmacists can support this. Patients will
also receive online information, screening programmes and education through community
teams. Informatics systems will also allow patients to access their own records online.
Where patients do need access to a professional, this will be made as easy as possible
through a simple, convenient point of entry. Practices remain the centre for most routine
primary care. Every practice will continue to offer core GP services, as well as working with
other practices in their locality to provide additional services.
We will explore how appointment lengths can be varied according to the need, offering
patients with long-term and/or complex needs longer appointments. Patients with non-urgent
care needs will be able to contact GP practices and be offered triage on the telephone before
appointments are made ensuring care is appropriate. WL CCG will also explore how patients
could better access consultations by Skype, e-mail or telephone.
Page 17
WL CCG will ensure a number of practices are open from 8:00 a.m. – 8:00 p.m, 7 days a
week. For patients with episodic needs, appointment choices will be broadened to the
network level. They will be offered a choice of convenient appointments across all the
practices in their network. This will enhance the flexibility and accessibility of primary care.
Proactive
Many simple procedures, diagnostic tests and specialist therapies currently require patients
to attend a hospital outpatient appointment. This forces patients to make trips into hospital at
potentially inconvenient times to receive care that could be provided more cheaply and
effectively in an out of hospital setting. Patients have little control over when, where and by
whom their care is provided.
In line with the Shaping a healthier future reconfiguration programme, we will move a
significant proportion of planned care services into an out of hospital setting. Broadly,
two types of service will be affected:


Simple diagnostic tests (e.g. phlebotomy)
Specialist services that could be provided more effectively in the community (e.g.
enhanced primary care diabetes services)
Individual GPs will retain responsibility for referring patients to specialist services and are
expected to ensure that all referrals are clinically necessary and appropriate to patient need.
To support this, referrals will first be directed to a single Referral Management Service
(RMS) responsible for triaging patients, validating the original referral and passing on
approved referrals to the appropriate service. GPs will also receive training on the
recommended criteria for using diagnostics test (such as MRI) to avoid unnecessary or
duplicate tests.
Re-designed planned care pathways will empower patients to make decisions about their
care. A higher proportion of planned care will be delivered closer to patients’ homes via
community facilities and enhanced GP practices, rather than in hospital locations. Services
will be provided by a variety of organisations from a range of locations in the borough,
providing patients with increased choice and flexibility. Networks will utilise the skills and
expertise of their member practices to offer a wider range of services than single practices
including: minor surgery, wound care, contraceptive services, children’s services, anticoagulation, continence services and foot care. West London CCG is currently redesigning
care pathways e.g. musculoskeletal services to move care from hospitals into community
settings.
Hubs will be centres for planned care in the community. Within our hubs, GPs,
consultants and other health professionals (including nurses and therapists) will provide
outpatient clinics across a wide range of specialties supported by relevant diagnostic
equipment and facilities including MRI and X-ray, supported by clear referral guidelines to
avoid unnecessary tests. The combination of expert staffing and appropriate diagnostics
means that we can ensure that, wherever possible, patients are assessed and treated in a
single visit to a hub.
Co-ordinated
Across West London, patients will receive co-ordinated care through the
implementation of the Putting Patients First (PPF) framework. This will include the
provision of proactive person centred co-ordinated care that is delivered closer to home and
results in the avoidance of unnecessary non-elective hospital spells for high intensity user
patients where clinically appropriate. Patients will be risk stratified to identify patients at risk
of hospital admission so that they can be proactively managed.
Patients with long term conditions (LTCs), co-morbidities or complex needs will receive coordinated and holistic care, with a single point of access into the system. PPF will support
Page 18
patients to self-manage where possible by focusing on empowerment and community
support. Patients and their carers will be fully involved in the development of integrated care
plans, which capture the full range of their health and care needs. GPs will work with a range
of other professionals to implement and monitor care plans for those patients that need them;
these will be reviewed at least annually. This care plan will include primary care, community
care (including community nursing), social care and acute care.
In addition, the GP will be responsible for identifying and appointing a named case manager.
The case manager will work with the GP to draw in relevant professionals and co-ordinate
the care plan, helping patients navigate the range of services they are receiving, and
responding to any crises. Networks will further develop the management of patients with
long-term care and/or complex needs, for example in West London where we have
developed a dedicated end of life centre which provides providing holistic palliative support
to support patients in the community. The centre will offer 24 hour support from a dedicated
palliative care service, including access to a specialist consultant.
Delivering care in a coordinated manner through multi-disciplinary working of health and
social care professions will transform the way that patients are supported and help them live
more independently in the community.
4.1.4 Organising principles
In our new model of out of hospital care, the system is organised at four different levels – the
GP practice, the Network, the Locality and CCG wide. Each level offers a different
combination of accessibility and scale – important because different types of services require
different user-population sizes. Three of the levels at which the system is organised - GP
Practices, Localities and CCG-wide – are already actively used. However to ensure we meet
the need for additional capacity and for coordinated and integrated care, GPs will also form
(and work together in) Networks.
The CCG will continue to capture local needs and commission high quality, cost effective
health services on behalf of its local population. GP Practices will remain at the centre of the
provision of primary care; indeed they will play a more significant role in the new model as
GP’s will be enabled to take on a wide range of service delivery, including primary care
services, planned care services, and care co-ordination and management. Localities are
critical to the integration of out of hospital care - forming a bridge between the services
available at an individual GP practice and those available CCG-wide. Localities are also the
area across which networks of GPs will be working together to deliver care.
Networks bring groups of local GP practices together to help them offer services and
manage patient care. They offer the opportunity to realise the following objectives - extended
hours, more GP appointments, shared skills, an enhanced primary care offer and a wider
range of planned care services in community settings. Patients will also have access to a
single point of contact that enables patients to coordinate and integrate the care they receive.
Networks will play a central role providing co-ordinated care and ensuring that primary care
can realise the benefits of scale. The number of localities and networks will vary by area – in
West London CCG, practices have organised into two networks under the two CCG
localities (North and South).
4.1.5 Care settings
Organising out of hospital care into four levels supports planning and commissioning
processes, but it is important to be clear about the actual settings in which patients will
receive out of hospital services and the type of services which will be delivered in each
setting. Services will be provided by a variety of organisations and from a range of locations
across West London, providing patients with increased choice and flexibility.
Delivering our vision for out of hospital care will require changes to how we operate – there
will be a growing role for GPs who will have to work together to organise patient care and a
Page 19
requirement for all health and care professionals to work more closely together in multidisciplinary teams . The new model needs to balance the continuity of care important for
some patients, with the rapid access important for others, using differentiated models of care.
Not all planned care services can be delivered from GP practices so we will also introduce
hubs – one hub per locality where there is sufficient out of hospital activity to do so.
So in the new model of OOH care, the four locations in or from which services will be
delivered are:
•
•
•
•
At home
In GP practices
In a designated GP Practice (as a result of an inter-practice referral to another GP
practice in the network)
In a hub.
Services will also continue to be delivered across the CCG as a whole for example the 111
service, 24 hour Urgent Care Centres, secondary care and specialist community-based care.
Home
For many patients, particularly frail elderly patients, care in the home is essential to improving
the quality and experience of their care. Supporting people to live and be cared for in their
own homes is also an important contributor to reducing unnecessary admissions to the acute
setting, reducing bed stays, or to care homes. Care in the home must be underpinned by a
supporting infrastructure of out of hospital care provided by multidisciplinary teams and rapid
response teams.
In GP Practices
General practice is at the heart of our proposals for out of hospital care. It provides the
central point of access and co-ordination around which the rest of our proposals are built. All
West London GP practices will continue to provide core primary care services for all of their
registered patients. Patients will be able to book both routine and urgent appointments with
their practice during working hours. Core standards of both equity of access and quality of
provision will be assured across the CCG population. Practices will work across locality
networks to manage requirements for extended access and opening hours (national
requirements for access 8am – 8 pm seven days a week).
In a designated GP practice
Practices will work together in their networks to provide care during evenings and weekends,
with one or more practice providing extended hours access and urgent appointments on
behalf of each network. Patients requiring care at these times will be signposted to another
local practice in their network, or to the hub serving their locality (see below for more on
hubs). GPs working together in Networks will play a central role in providing improved coordinated care, and in ensuring that primary care can realise the benefits of scale.
In a Hub
The hubs are a key component of our new model of out of hospital care providing local
services to patients above and beyond what is currently available in general practice and
wider primary and community care settings. Hubs will enable us to develop and improve out
of hospital care and give the new model of care three major advantages over the existing
model: they will provide access to a range of out of hospital services in convenient settings;
the additional space needed to meet demand being redirected from the acute sector, and a
site in which health and care staff can be collocated, supporting whole-systems integrated
care and multi-disciplinary working.
Page 20
Hubs will both deliver services on-site and be used by clinicians and other professionals as
base from which to deliver services in the community. They will be a shared resource across
localities supporting the collocation of clinicians and other professionals and ultimately the
delivery of integrated care to patients.
Differences between the north and south regions of the CCG necessitate a local solution in
each area. Establishing two hubs- one in each locality – is a step towards delivering these
local solutions.
Figure 6: Proposed Hub sites
For patients, the delineation of north and south will be less clear as the hubs will offer
consolidated services and be accessible to local people from both localities. They will support
out of hospital delivery by providing a facility to carry out outpatient appointments, deliver
integrated care pathways and provide space for joint working by multi-disciplinary teams.
They will deliver planned care services, supported by appropriate diagnostic facilities. Some
of the tests currently provided in hospital, will be moved out of hospital and made available in
hubs. The hubs will offer outpatient appointments, deliver integrated care and provide space
for multi- disciplinary teams. West London CCG is currently redesigning care pathways to
move care away from hospitals into community settings; Hubs will be used as centres for
planned care in the community, delivering high quality care closer to patients’ homes.
Wherever possible, patients will be assessed and treated in a single visit to a hub. Also within
the hubs will be community voluntary services whose work is complementary to the health
services being provided in the hubs.
The hubs will be supported by trained staff and accessible during extended hours. Where
appropriate, GPs or the 111 service will be able to refer patients directly to the hub for tests.
In addition WL CCG’s hubs will offer a range of planned and anticipatory care support for
people with long-term conditions and patient education and carer support programmes to
support patients to self-care. These will provide patients with up-to-date information about
their health and care, and about the range of services which are available to support them.
They will also ensure we can provide carers with the support they need, including in relation
Page 21
to their own health and wellbeing. The range of services to be provided at a hub is expected
to include:
 Paediatric services
 Musculoskeletal services
 Dermatology services
 Cardiology services
 Diagnostic services
 Diabetes services
Respiratory services
Establishing hubs will provide the facilities and setting necessary to achieve our out of
hospital standards and help us deliver against QIPP and support a system-wide shift in
resources, from the acute sector to community and primary care providing services in more
local and lower cost settings. The table below summarises the care that will be delivered by
each of the four settings described above:
Figure 7: Care to be delivered at each setting in the new model
4.1.6 How this will look to patients and carers
If we successfully deliver against our new model of out of hospital care, it will make a real
difference to the way patients experience our services, the quality of their care and ultimately,
to patient outcomes.
When we pull together all of the developments at local, regional and national levels, we arrive
at a transformed system of care which delivers more services out of hospital, in settings
as close to the patient’s home as possible. The care patients with the most complex
needs and those suffering from long term conditions receive is well integrated and
coordinated - the different professionals involved work across health and care systems to
Page 22
ensure proactive and coordinated care. Patients have better access to primary care and to
their GP (urgency of access, continuity of access, convenience of access) whom they work
with to develop and manage their care plans. GPs support each other to deliver this service
by working across networks. The system we hope to create is represented by the diagram
below. All the changes being made respond to patient feedback and help enable West
London’s new model of care.
Figure 8: The transformed system25
Shaping a Healthier
Future
More health services
available out of hospital,
in settings closer to
patients’ homes seven
days a week.
Whole Systems
Integrated Care
Patients with complex
needs receive high quality
multi-disciplinary care close
to home, with a named GP
acting as care co-ordinator.
GP as lead for
patient care
Community
hubs
Primary Care
Transformation
Patients have access to
General Practice services
at times, locations and
via channels that suit
them seven days a week.
Patient
+
Urgent
appointments
+
Supported to self
manage
More local
diagnostic
equipment
Convenient
appointments
Time available
for care plans
More
specialised
hospital care
GP network
Continuity
appointments
MDT meetings
led by GP
Acute
reconfiguration
+
Information
systems and
record sharing
Capitated
budgets
Less
inappropriate
time in hospital
We have developed some patient stories below that bring to life our vision and new model of
care.
Example 1: Jack
Jack is 8 years old and lives with his mother and two sisters in Chelsea. Jack has severe
asthma. He uses three inhalers and has had recurrent short stays in hospital as a result of
his condition. Two years ago he was admitted to hospital with his asthma four times over a
short space of time and as a result missed several weeks at school.
Jack’s mum used to panic when his asthma flared up; she used to be frightened that he
might die from his asthma and became very scared if his condition deteriorated. She believed
that A&E was the only place that could help and would turn up there if she felt things were
getting bad. She also used to worry that at some stage his wider life (for example his
schooling) would be disrupted again for a significant period of time because of his health.
But last year local services were redesigned and things have changed. Jack now has an
25
Challenge fund
Page 23
integrated care plan that includes an asthma self-management plan on his Mum's mobile
phone. This helps her to spot when his condition is deteriorating, helps the family deal with a
severe flare up, helps Jack’s Mum adjust his medication and lets her know when to schedule
an appointment for him at their GP practice. Mum also now knows how to access information
about asthma care though the web and has spent time with a local mum who also has a child
with severe asthma, talking about their experiences and exchanging ideas.
Jack’s GP and practice nurse work closely with the support of hub services and specialist
advice and guidance. Jack's integrated care plan was devised and agreed with his Mum,
their GP and Practice Nurse, Paediatric Consultant and School Nurse and it is shared
electronically by all the local agencies. Jack's care co-ordinator is a GP from his registered
practice and his Mum knows to contact her if there is a problem. Professionals caring for
Jack operate as one virtual team, working in an integrated way to co-ordinate his care, share
information and ensure effective access and proactive control of his condition. Shared
electronic records and exemplary communication between different staff groups – each of
whom understands their contribution to Jack’s care – ensure an excellent patient
experience.
Example 2: Rita and John
Rita is 73 and John is 79. They are an elderly couple with complex needs who live in
Ladbroke Grove. John has dementia with significant memory impairment - he sometimes
becomes aggressive and has a tendency to wander. Rita has become frail of late and is
finding it increasingly hard to cope. Their son had suggested that they might consider moving
to a care home, but the couple would prefer to continue to live in their own home.
Rita and John access care and support from a range of different health professionals and
care agencies. They used to get confused about which organisation they should go to for
what support and found themselves having to tell different health and care professionals the
same story over and over again. No one seemed to have a clear understanding of their
situation and Rita was never quite sure who was supposed to be doing what, or who to call if
there was a problem.
But since 2015, the organisations and professionals that help Rita and John have begun to
join up their services. Access to support is simpler and the coordination of these services has
improved considerably. As John's main carer Rita feels better supported and is more
confident that the team of professionals involved in their care are working to the same care
plan are able to access the information they need, with each person clearly understanding
their role in John’s care. Rita knows to contact their Care Coordinator if she has a question or
a new problem arises. She also has a handwritten copy of John’s Integrated Care Plan which
details John’s physical health, social care and mental health problems and gives her the
details of key contacts.
John suffered a fall last week but after assessment by their GP he was able to stay at home.
Rita was glad John didn’t have to go into hospital as a stay away from home tends to
exacerbate John’s condition making him much more confused. To help prevent any further
incidents, Rita was given some advice on reducing the likelihood of John falling again.
John and Rita’s flat has been adapted to ensure John stays safe as he sometimes used to try
and leave the property late at night in a state of confusion causing Rita to lay awake listening
for the front door. Their door looks have been adapted to prevent this happening, giving Rita
some peace of mind. John also now wears a watch that triggers an alarm if he wanders too
far from the house at any time of day or night.
Rita also gets support from a local voluntary service. They provide a carer for John for two
hours every Wednesday afternoon so Rita can run errands or visit her friend for a coffee. Rita
feels more confident in her ability to remain at home with John and care for him.
Page 24
Key points:
 West London’s new model of out of hospital care will ensure care is accessible,
proactive and coordinated.
 It will be organised across GP practices, networks of GP practices, localities and CCG
wide.
 Care will be delivered from 4 main out of hospital settings – home, GP practice,
designated GP practice (part of a network) and a hub. Hubs are a new addition and a
key component of WL CCGs new model of out of hospital care.
 Each WL CCG locality will have access to one of the hubs.
 Patients will see a transformed model of care in West London with more services
available out of hospital and closer to home, better access to primary care supported
by 7 day working, high quality care, multidisciplinary working and better coordinated
care (particularly for those with complex needs).
 The new model will require changes to workforce, informatics and estate- expanded
upon in section 2 of this SSDP.
Page 25
Part 2
Page 26
5
Delivery implications - workforce, informatics, estate
The WL CCG new model of care is not just about delivering more care in out of hospital
settings; it is also about delivering care differently. We are confident our new model of care
can achieve a patient-centred and integrated system of accessible, proactive and
coordinated care. However, to do this we will have to make major changes to the existing
health and care infrastructure as the way systems and services are currently configured will
not enable us to deliver our model. In chapter 4 we noted the particular impact on three
specific areas:



Workforce
Informatics
Estate
Significant work is underway to help us understand the scale of transformation required in
each of these three areas. In the sub-sections below we touch upon each area in turn,
outlining what WL CCG’s new model of care will mean for the local health and care
infrastructure.
We first discuss workforce, this includes the new roles, skills and ways of working that will
be required to support self-management, primary care transformation and whole
systems integrated care and the associated education and training requirements.
We then discuss informatics and the role this will play in the achievement of accessible,
coordinated and integrated care, for individual patients and across localities.
We then discuss out of hospital estate. Transformed out of hospital estate is necessary to
meet demand and achieve WL CCGs new model of care. The estate must be high quality,
offer good patient access, support coordinated and integrated working, help the CCG
achieve its QIPP savings, and ensure primary and community care can manage increased
demand as a result of activity moving out of the acute sector. This SSDP focuses most
heavily (from chapter 6 onwards) on how West London’s estate will achieve these objectives.
5.1
Implications for the workforce
All aspects of our future model of care will have significant implications for the health and
care workforce. These are explored below.
5.1.1 Patients and Carers being supported to self-manage
Supporting patients to self-care, and the increasing involvement of patients, their families and
carers in their care (including, but not limited to, care planning), will have significant
implications for the workforce. Aside from the cultural shift, there are implications in two main
areas:

Patients and carers as ‘part of the workforce’: In the new model of care patients will be
supported to self-manage and contribute to the design of their care plans. Care plans will
be co-designed with patients and carers. Coupled with an outcomes driven approach to
managing care, this ensures that patients and carers have a key role to play in the
improving their own health and well-being. Alongside this, many services, such as
Telecare require the patients to administer parts of their own care. As care is transformed
and co-production becomes a reality, patients and carers become effectively part of the
workforce. To do this, they will require advice, information and support, and in some cases
(such self-administering telecare) formal training. We will need to put in place a range of
programmes including: patient and carer education programmes; carer support
programmes
Page 27

Empowering patients and carers - professional roles and skills: We will also need to
ensure that health and care professionals have the skills, competencies and time to
support and empower patients and carers in their new role, and that their interactions with
patients reinforce, rather than undermine, patient empowerment. Staff will require training
to enable and support service users to self-manage. While some staff will have these
capabilities already (such as motivational interviewing), there is a need to specify clear
technical standards and train staff to them, specifically to delivery evidence-based selfmanagement. Such skills will be important for the full range of community-based staff,
including those providing ‘instant’ access and advice (such as community pharmacists)
as well as those providing planned and long-term care.
To bring about these required workforce changes we will need to: develop patient and carer
education and support programmes - these will require suitable funding, staffing and space
for programme sessions to take place, and; develop staff training courses to ensure that staff
have the skills and competencies to support self-care and co-design - staff will require the
time, funding and cover to attend these courses. In the longer-term, it is hoped these
changes will help reduce demand for services as low-level needs are met through self-care.
This will have implications for the primary and community care workforce, in terms of both
numbers and skills.
5.1.2 Primary care transformation
Our proposals for transforming primary care, including providing an increasing range of
services through networks, providing differentiated appointments and increasing access to
care to seven days a week, will have wide-ranging implications for the primary care
workforce. We will need to develop new workforce roles, adapt existing roles and ensure
people learn new skills, and work together (across settings, organisations and professional
groups) in new ways.

New Roles: The development of Primary Care Navigators (PCNs) gives us a significant
opportunity to ensure all primary care practices have access to specialist skills in
community settings. Examples of new roles include Care Navigators (acting as the first
point of contact for care and care planning between the GP and providers ensuring coordinated and joined-up care); Case managers (which may be a GP or another
professional) acting as the first point of contact for care and care planning with patients a
higher risk of hospital admission, and; Patient educators offer help and support for
patients to self-care.
Community-based professionals will also form links with secondary care clinicians,
through our Network Learning Forums allowing them access to specialist expertise
across a network which would not be possible for individual practices. Additionally,
business and operational management will be a key aspect of unlocking the operational
benefits and efficiencies of running a network. Networks will be considering how best to
organise their management arrangements as they evolve.

New skills: Our transformation of primary care will require existing primary care
professionals to both increase their skills and become more specialised. For example:
o
o
o
GPs focussing on patients with long-term conditions (on behalf of their network)
will require specialist skills and training relevant to LTC management. These skills
will vary depending on local need.
Practice nurses, with appropriate training, will provide an increased range of care,
particularly for episodic needs where continuity of care is not required. Again,
specific training requirements will reflect local needs
All staff will have the opportunity to work more flexibly and increase their skills.
For example, ANPs taking on repeat prescriptions, health care assistants
administering vaccines, and receptionists triaging patients and taking blood
samples.
Page 28
Importantly, in providing scope for practitioners (from all professional groups) to increase
their skills, networks will also increase the career progression and satisfaction of those
who work in them, and make general practice (and North West London) a more attractive
place to work. This is essential in ensuring that we have sufficient, high quality staff to
realise our future ambitions.

New ways of working: The formation of primary care networks will require a complete
transformation in how primary care professionals work together. Realising the full benefits
of networks will require high levels of trust between constituent organisations and,
importantly, between professional groups. These new ways of working include:
o
o
o
Working in multi-disciplinary teams: Primary care networks will host multidisciplinary teams of aligned professionals who will be able to contribute directly
to care at a practice level. Networks will also manage episodic demand, enabling
GPs to spend more time with LTC patients.
Sharing skills across practices. Practices working together in networks will allow
patients to be referred to GPs and other health professionals, including GPs with
a special interest and specialist nurses, in other practices in their network. This
will therefore break the exclusive relationship between patients and the practice
(or individual GP) at which they are registered. Sharing skills therefore has the
potential to provide significant benefits to patients, but will also require a very high
level of trust between professionals that ‘their’ patients are getting the care they
need from others.
Centralising HR management and workforce planning across the network: Back
office centralisation, integrated telephony / appointment booking / staff rotas;
Practices giving up some autonomy in exchange for greatly increase efficiency.
Our vision for the transformation of primary care therefore has a significant number of
implications for the workforce. There are therefore a number of essential actions to ensure
that the future workforce will be available to realise our ambitions, these include:
implementing community learning networks (CLNs) to ensure all staff have the skills they
need to support integrated care and other service transformations, and; developing a
programme to make primary care careers more attractive, and to increase the attractiveness
of GP training, across North West London, to ensure we can recruit and train the high-quality
staff we need to support service transformations.
5.1.3 Whole systems transformation – delivering whole systems integrated
care
As well as our proposals for transforming primary care, our model of whole systems
integrated care will have significant and wide-ranging implications for the workforce. It will
require the development of new roles, the development of new skills and the development of
new ways of working. Each of these is discussed in turn below:

New Roles: transforming our services and the ways we work will require us to develop
new roles. These were outlined in the workforce strategy for North West London, From
Good to Great and are being developed further by each CCG.

New skills: our proposals will require existing healthcare professionals to work differently
in the future. Specialist, community and district nurses and other health professionals will
provide a greater range of care in the community and in patients’ homes for example face
to face assessments, rapid interventions at home, the provision of on-going care and
monitoring, re-ablement support and home or community based care for patients at the
end of life. Staff will have to draw on colleagues within their multi-disciplinary team as
appropriate. Specialist Consultants will facilitate the shift to out of hospital care (for
example by providing clinics in hubs), ensuring patients receive all the care they need in
a community setting. Moving diagnostics, outpatient clinics and planned care procedures
out of hospitals will require an increase in staffing, and/or the movement of some staff out
Page 29
of hospital settings. In addition we will make greater use of the third sector to support selfmanagement and we will ensure our Primary Care Navigators are fully embedded

New ways of working: Integrating care will require professional teams to come together
around the needs of patients, rather than organisational silos. This will have profound
implications for how health and care professionals work together. Integration around
patient needs will only be possible within an environment of inter-professional trust and
respect. Professionals will require an understanding of each other’s’ roles in delivering
care along the patient pathway, and trust they that will deliver that care effectively.
Building this trust will mean breaking down barriers between current organisations,
including within healthcare as well as between health and social care. For multidisciplinary teams to be able to communicate effectively there is a need for a shared
language – and therefore a shared understanding of patient needs - across health and
social care. This suggests a shared core syllabus of skills across all professionals and
providers, to ensure that everyone has the skills they need to make multi-professional
collaboration and integrated care work effectively.

Co-design and co-production: WL CCG will need contributions from all partners in
order to extend the range of community services and ensure integrated, coordinated care
for our patients. Partners and providers from across health, local government and the
community and voluntary sector will co-design and produce services and care. The
transformation of primary care – which underpins the new model of OOH care – will only
be possible if professionals, patients and carers understand the new model, its rationale
and the benefits it will bring.
5.1.4 Education and training
All of our proposals depend on staff having the right skills and competencies to deliver highquality, appropriate care, and many of our proposed changes will require staff to change and
increase their skills. If we are to achieve this, we must ensure that a suitable training
infrastructure is in place, so that all staff who would benefit from training can access it.
Education and training should be provided as close to the relevant setting of care as possible
to ensure it can, at all times, remain relevant and focussed on patient needs. Therefore, as
more care is delivered out of hospitals, there will be more rotations through non-acute
settings for not only pre-registration students, but also for qualified professionals, as part of
their continuous professional development.
Figure 9: Implications for workforce
Implications for the workforce...
Primary care
Patient /
self-care
New roles
New skills
New ways of working
The ‘empowered patient’
and ‘empowered carer’ are
equal partners in care
planning.
Staff skills to support selfcare e.g. motivational
interviewing.
Physician’s assistants
support seven-day access.
Differentiated appointments GPs at the heart of multirequire GPs to develop
disciplinary teams.
specialist skills for patient
groups.
Referral between GPs
requires increased trust
Practice nurses are able to between practices and
provide an increased range staff.
of care.
Centralisation of workforce
New skills requirements for planning and HR processes
non-clinical staff (e.g.
across a practice network.
network management,
triage)
Workforce numbers
Care is ‘co-designed’ by
patients and professionals.
Numbers increased by new
roles.
Workforce increases
(across professions) as
care moves from hospitals
to community settings.
Page 30
Acute care
Integrated care
Case Managers provide
first point of contact for
complex LTC patients.
PCNs provide support for
non-clinical elements of
care
Specialist staff to support
community diagnostics
(e.g. audiology,
radiography)
Specialist staff move from
acute to community
settings.
Community and district
nurses provide an
increasing range of
interventions.
Specialist skills support
shift of procedures from
acute to community
settings.
Care provided by multidisciplinary teams.
Numbers increased by new
roles.
A common language
across health and social
care.
Workforce increases
(across professions) as
care moves from hospitals
to community settings.
5.2 Implications for our informatics
Delivering transformed out of hospital care relies on more effective use of existing and new
informatics systems. These systems must provide the ability to share data, information and
knowledge across organisational and geographical boundaries. The West London health
care system will move towards a single system (SystmOne) to ensure effective
communication and joint working across localities and integrated, coordinated care. This will
be aligned with our community and other providers, who will be able to share patient
information, including test results26.
In addition, a shared informatics strategy for NW London has been developed. The strategy
outlines how sharing data across Health and Social care will increase patient care,
experience and access to information and improve operational efficiency, commissioning and
planning. This integrated approach will deliver:

Better care for service users through systems and information that empower them to
access services and inform their care and choices

Better informed and supported professionals having accurate and timely information
available to make better decisions, and technology to support ways of working that
deliver higher quality care more efficiently

Better outcomes through optimising use of systems and technology; providing access
to information to allow commissioners to make more effective procurement and
commissioning decisions.
This will be supported by professional design, delivery and governance throughout the
Informatics estate. To deliver this, a common set of design principles are being used across
North West London:
Figure 10: NWL informatics design principles
26
Out of Hospital Delivery Strategy West London CCG
Page 31
These design principles will have a different effect across the CCGs in North West London.
In West London, , three major elements will be delivered to support transformed out of
hospital care: interoperability to enable joined-up and co-ordinated care provision;
developing our 111 service into a telemedicine service (or an alternative solution); using
informatics to improve patient access.
Each of these systems and approaches are expanded upon below.
5.2.1 Interoperability to enable joined-up and co-ordinated care provision
This is about using information technology to enable joined-up and co-ordinated care. This
will mean developing an integrated, shared, electronic health record across the CCG to
deliver high quality clinical information safely, where and when it is needed and in a way that
demonstrates effective information governance
Integration can only be achieved if we transform the way in which we share relevant care
information between settings and providers. There is a clear goal of developing an
integrated, shared electronic care record across the CCG that delivers high quality clinical
information where and when it is needed, subject to appropriate information governance,
enabling a “whole system” approach. Future architecture will allow GP practices, hubs and
the 111 service to share patient information seamlessly and confidentially, ensuring that
services can be co-ordinated around the patient. Patients will benefit from better information
being available to support the clinical decisions being taken about their care with faster
communication and turn-round times.
It will also help improve staff working lives, improve resource utilisation and potentially save
costs by avoiding unnecessary tasks such as telephoning and faxing providers for
information that has not yet been received; and better information for management and
governance. Most importantly, patients will receive better care because clinicians will be
better informed about their conditions. [
Phase 1 - GP to GP information, data sharing and systems

GP systems are largely fit for purpose to facilitate more integrated out of hospital care and
as such they will remain in use for the foreseeable future. The focus on GP systems is
therefore on ensuring that practices use them in the most effective and efficient way to
deliver care to patients; and on supporting practices when changes are required, for
example new pathways or protocols, or reporting requirements.

Alongside this GP systems will continue to be integrated with central NHS systems,
including:
o
Choose and Book: where the CCG will work with practices and local providers to
improve the rate of electronic referrals.
Page 32
o
E-Referrals: Procurement for a new e-Referrals system to replace C&B is in
progress, implementation of which is due to start in 2014.
o
GP2GP: A central facility which supports patients who move from one practice to
another by transferring their records electronically between GP systems. Plans to
address some limitations are in progress.
o
Electronic Prescription Service (EPS2): Initial work, such as ensuring that
pharmacies have the required network connections and nhs.net access will be
carried out as a prelude to fuller planning on ESP2.
GPs also use additional local systems which are not integrated with their systems and
these will be improved:
o
The WLCCG Extranet: a repository for information used by GPs - for example
pathway and protocol documentation and standard referral forms.
o
The North-West London GP Portal: operated by the CSU - this gives access to a
variety of clinical data.
o
Risk stratification tools: risk stratification is fundamental to the strategic goal of
driving care to the patients by whom it is most needed. It is likely that future
systems (potentially aligned with care data) will be more closely integrated with
GP systems, further increasing the focus on data quality. Currently the BIRT2 tool
is being rolled out to GPs from the CSU although this is fed by extracted SUS
data rather than directly from GP systems.
In the longer term it is expected that GP systems will evolve from their current functions of
record keeping and communicating, to give greater support to clinical decision-making.
Examples of “intelligent” decision support tools already available include pathway
selection (e.g. Map of Medicine or NICE)
Phase 2: GP to core out-of-hospital services data
WLCCG’s overall aim is to drive towards an integrated, shared electronic health record
across West London that delivers high quality clinical information where and when it is
needed to deliver care, subject to appropriate information governance, enabling a “whole
system” approach. The information to be shared includes the following:
o
Interoperability to shared care plans and information: Interoperability and
brokering technology will information in the GP record that may be useful to a
clinician in another care setting, e.g. an out of hours doctor or in the Urgent Care
Centre, e.g. an out of hours doctor or in the Urgent Care Centre, such as those
held as part of the Integrated Care Pathway. In some cases where the GP system
may be extended into out-of-hospital services further expand the scope of
requesting tasks and establishing automated workflows between partners. This
would also include information about the patient’s preferred end-of-life option,
recorded in the Co-ordinate My Care system.
o
Clinical Correspondence from providers: sent to GPs to inform them about
episodes of care: a typical example is a discharge letter when a patient leaves
hospital. Correspondence received by GPs spans acute hospitals, community
healthcare and mental health, out of hours and 111 services, urgent care and
walk-in centres and social services, plus potentially other organisations that may
emerge under the Any Qualified Provider principle. This will also need to be joined
up with the role of care co-ordinators.
o
Diagnostic Cloud information: the results of pathology or radiology investigations
requested by the GP or performed during an acute hospital episode.
o
Shared Clinical Records: information in the GP record that may be useful to a
clinician in another care setting, e.g. an out of hours doctor or in the Urgent Care
Centre, e.g. an out of hours doctor or in the Urgent Care Centre, such as those
held as part of the Integrated Care Pathway. This would also include information
Page 33
about the patient’s preferred end-of-life option, recorded in the Co-ordinate My
Care system.
Phase 3: Whole-systems information sharing
Sharing information across health and social care systems to ensure patients receive
coordinated, integrated care will require two major changes:
o
Interoperability between health and social care: This will be extension of the
interoperability architecture required for sharing information between Healthcare
providers. Historically information sharing between health and social care has
been limited and fragmented. There are some key enablers through the better
care fund that will support the foundations for sharing including the adoption of the
NHS number as the universal identifier. Care-place system for social care will also
offer real options to share sensibly data between health and social.
o
Whole-system Integrated Care - data warehouse: The proposal for a partnership
data warehouse for WSIC that will develop, mobilise, manage and delivery
integrated care for the future. Data from various health and social care providers
will be collected, assembled and linked to provide valuable information to
determine population & outcomes, contracting and financial planning and actively
support the delivery and monitoring of integrated care.
Phase 4: Sharing information with patients and service-users
WL CCG will work with partners to consider approaches to actively sharing information with
patients and service-users that achieve the following outcomes:
o
Accessible and convenient: Accessible and convenient care through online
booking services.
o
Improve service utilisation: Improve service utilisation using reminders and alerts.
o
Empower patients through access to timely, relevant information: Empower
patients through access to timely, relevant information about their care and
support with self-management.
5.2.2 Developing our 111 service
The use of 111 is a single point of access to the health system is a real opportunity for
helping to transform out of hospital care. Without IT integration 111’s ability to deliver to its
full potential will be limited.
The policy direction for 111 indicates two potential future developments: the development of
direct booking from 111 into other services, and the 111 service having access to patient
records. Special Patient Notes and Co-ordinate My Care are already accessible by the 111
service, and in the future there is potential for the service (and the GP out of hours service) to
have access to the patient’s GP record (with appropriate information governance protocols in
place). This would inform the decision-making of 111 and GP out of hours clinicians and
support the appropriate direction of patients around the urgent care system.
The implementation of direct booking from 111 into other services, such as Urgent Care
Centres, primary care core hours or weekend opening service, or community services, would
enhance the patient journey through the urgent care system and would reduce the need for
duplication and hand-offs.
5.2.3 Using informatics to improve patient access and engagement
Patient and public engagement is at the centre of Out of Hospital implementation, it is vital
that patients are fully involved. Communication with patients about the services they receive
from GPs and other out of hospital providers, and the provision of health information in
Page 34
general is currently achieved through a number of channels. The main electronic means of
communication include information websites and health portals operated by GP practices,
the CCG, providers and the Department of Health. These are perceived as adequate, but in
future patients will expect much greater capabilities from digital channels. Expected
developments might include the following:
o
Social media communication channels
o
Health information portals, both public and private – including potentially
dashboards ranking the performance of various healthcare providers
o
Technology that makes it easier for patients to self-manage, particularly for
long-term conditions
o
Greater use of mobile technologies such as smartphone apps, to help
patients gain a greater understanding of their own conditions, particularly
younger patients
o
Consultation on proposed changes to local and national healthcare
delivery, for example service reconfigurations
o
Feedback channels to allow patients to comment on the quality of service
they have received from the healthcare system (note: GPs will be
measured using the Friends & Family criteria already applied to acute care
– “would you be happy for your friends and family to receive care in this
organisation?” by the end of 2014/15). In addition patients are able to
feedback at practice level through their Patient Participation Groups and
patient experience feedback forms at practice level.
The following table further outlines how this will happen:
Our Commitment
How we will deliver
Patients will be involved  Ensure patient representation on key committees and
decision making bodies, including the Governing Body
 Work with Healthwatch and other key partners to ensure a
board range of patients and public are consulted with
Patients will be
 Be pro-active in explaining service change and outlined
informed
reasons for change through regular updates
 Use of clear concise language and work with partners to
ensure a consistent message
Shaping services
 Use national and locally collected patient experience data to
inform decision making
 Commission services with evidence of listening to patient and
public views
 Pro-active engagement to enable input into existing and
future plans
Feedback
 Explain how patient and public input has informed decision
making.
 Demonstrate how services have reacted to patient and public
feedback
5.3 Implications for our estate
5.3.1 The need for estate transformation in West London
Page 35
West London’s new model of out of hospital care is being driven by both the need to meet
rising demand and the need to ensure a financially sustainable health system. It reshapes
the local health and care system to ensure these challenges can be met. The top down QIPP
savings which WL CCG must meet in order to deliver a balanced health economy by 17/18,
and the bottom up objectives for WL CCG’s new model of care, lead to a desired volume of
activity to be delivered in an out of hospital setting in the future. This has implications for the
capacity and configuration of the local out of hospital estate and transformation of the
estate will be required.
The amount of activity likely to move out of the acute sector (or be re-provided in an
alternative way in an out of hospital setting) represents around a 25% increase in demand.
This is a combination of demographic pressures (more people), non-demographic pressures
(people using existing services more), and new OOH activity pressures (services being
redesigned to move activity away from an acute setting. The amount of activity delivered by
primary and community care providers will need to increase significantly for there to be an
associated reduction in the volume of care delivered in acute settings. The way in which this
care is provided will also need to change to ensure care is more accessible, proactive and
coordinated which implies the need for physical space capable of delivering this model of
care.
An increase in the volume of care being delivered in out of hospital settings will have two
major implications for the local estate infrastructure:

Pressure on existing estate as GPs have to manage a greater volume of activity
and ensure the buildings they deliver care from are well utilised, and meet required
standards (which some currently do not).

Pressure for additional estate to accommodate the increase in the volume of care
delivered in out of hospital settings, and the delivery of more specialist care locally.
West London’s new model of care also requires local estate infrastructure that is high
quality, offers good patient access, supports patient centred care, enables proactive and
coordinated working and facilitates whole systems integrated care and the realisation of
the benefits of collocation.
In West London’s new model, the response to these requirements is to appropriately
(re)develop the existing GP estate, and to manage remaining requirements through the
development of locality hubs. These hubs will:



Manage the increased demand that cannot be met by the existing GP estate.
Provide an appropriate and flexible base from which those delivering services key to
the new model can work - e.g. care navigators and case managers
Provide space for equipment and services moving into out of hospital settings - e.g.
diagnostic equipment, space for consultant clinics, space for planned care
procedures, accessible space for patient and carer education and self-care support
programmes.
Hubs will help localise and integrate the most common services people need for everyday
illnesses providing the additional capacity needed to deliver out of hospital care and enabling
a shift away from the acute sector. A service specification has been identified based on the
Whole Systems Integrated Care model and Service Delivery Plan. A draft service
specification for the proposed Hubs can be found in appendix 2. The list of services to be
delivered by hubs has been developed through engagement with the Senior Management
Team and is supported by detailed pathway redesign plans, Commissioning Intentions and
strategies.
So in our new model, our estate will be configured in the following way:
Figure 11: Estate configuration
Page 36
Without estate transformation in West London, it will be extremely difficult to deliver a
successful model of out of hospital care. With estate transformation we believe we can
achieve the following objectives:





Deliver a greater volume of care in out of hospital settings: through a well
utilised, high quality GP estate and the development of locality-based hubs.
Achieve whole systems integrated care: health and care professionals working
together with access to appropriate shared space from which to plan and deliver
integrated, patient centred care.
Deliver accessible care: better access to primary care, with facilities open at
appropriate times and well utilised across networks. This will support seven-day
services in health and social care, support patient discharge and prevent
unnecessary admissions at weekends
Deliver proactive care: simple procedures and planned care services including
diagnostics and testing available out of hospital in hubs.
Deliver coordinated care: a joint approach to assessment and care planning with
the involvement of relevant professionals and a real role for patients.
Key points: Estate transformation is being driven by 
The need to increase capacity to meet the anticipated 25-30% increase in
demand for out of hospital care - our current estate does not have sufficient space
or capacity to accommodate the anticipated levels of increased activity.

The need to deliver West London’s new model of out of hospital care – the new
model is not just about delivering more care in out of hospital settings, it is also about
delivering care differently. A ‘lift and shift’ of activity away from the acute sector, will
not enable us to adequately respond to the pressures on the system. We need estate
within which we can collocate services to facilitate whole-systems integrated care

The need to improve the quality of the GP estate in some areas in order to meet
standards - we need to ensure our estate is of sufficient quality - and it is currently of
poor quality in places. Our estate needs to conform to CQC and NHS England
Page 37
expectations around the safety and suitability of premises and the quality of provision.
5.3.2 The principles underpinning estate transformation
In the Out of Hospital Delivery Plan we noted the impact of OOH delivery will be felt at two
levels in West London:

GP practices, as GPs deliver more care in their practice on behalf of themselves and
their network.

Hubs (one in the north locality and one in the south locality), as services are
centralised locally to deliver more specialist care and we need convenient locations to
deliver this.
We also agreed we would transform our estate so it meets future requirements by firstly
improving the utilisation of the existing estate and secondly effectively targeting strategic
investment in new estate. In some cases local estate may be enhanced, moved or rebuilt, but
for this to be considered a viable option the estate in question must meet our estate
requirements, be able to meet standards and facilitate delivery of our new model of care.
Investment in new estate will be considered where suitable existing premises cannot be
identified.
To guide the estate transformation process we have developed a set of strategic criteria
against which all estates options will be assessed. These criteria will guide the estates
investment strategy over the medium term and ensure: investment plans meet a minimum
threshold; investment plans are prioritised appropriately, and; expectations of out of hospital
providers are consistently articulated across the NHS NWL landscape. The criteria have
been developed in conjunction with the Collaboration Board and were signed off on 12th
December (full details of the criteria are in appendix 3).
The strategic criteria that will be applied are summarised below.
1
Threshold
criteria
Proposed criteria
 Commitment to space utilisation: Plans for estate make
maximum use of spare capacity, and additional investment is
only considered when all spare space is used.
 Affordability and value for money: Plans are affordable, with
funding available from suitable sources.
minimum threshold, ensuring sufficient patient through-put.
 Condition of estate: Estate meets, or can be improved to
meet, minimum condition and access standards.
 Scope for expansion: Proposed estate can accommodate
new services.
2
Prioritisation
criteria
 Meeting local needs (hubs only): Catchment area meets
 Commitment to space utilisation: Plans with flexible estates
solutions are prioritised, including rooms that are multifunctional and can be re-purposed
 Condition of estate: Plans that improve the overall suitability
of the borough estate, by reducing the number of premises not
meeting requirements are prioritised
 Affordability and value for money: Plans are prioritised
based on their value for money
 Meeting local needs : Plans with more accessible premises
(e.g., proximity to public transport) are prioritised.
 Meeting local needs : Plans affecting larger populations are
prioritised
 Achieving our OOH strategy: Plans that make a larger
contribution to the delivery of the OOH strategy will be
prioritised.
3
Expectations of
service
providers
 Meeting local needs : Areas with higher levels of deprivation
are prioritised
 Commitment to space utilisation: Providers commit to full
space utilisation, including maintaining use of space and
sharing rooms where appropriate
 Alignment with OOH strategy: Providers commit to
integrated ways of working, including shared systems, network
working, integration with other services, and inter-referral.
 Alignment with OOH strategy: Providers commit to relevant
access / opening hours expectations, including
telephone/virtual access to consultations and extended
opening hours.
Page 38
Figure 12: Strategic criteria guiding estates development
The next step is to develop detailed estate plans. In transforming our estate we have
agreed the following actions are a priority:

Finding a home for additional out of hospital activity and integrating the delivery of
services (wherever it makes sense to do so).

Moving GP’s providing high quality services, into high quality premises.

Managing the impact of moving or dispersing patient lists belonging to GP practices
delivering a poor quality service.

Demonstrating the benefits of collocation to whole-systems integrated care.
Final decisions about the transformation of the existing GP estate are yet to be made.
Decisions about the development of hub estate are being made by WL CCG and NHS
England who are working together to agree the final programme of work with decisions
based on the availability of capital and alternative estate locally.
We cannot predict the exact amount of estate we will need over the next decade to deliver
our new model of care, but we can apply rigorous modelling techniques to existing data and
estimates of predicted activity, to understand how significant our estate transformation needs
are and what might be the most appropriate way to meet these needs.
5.3.3
Approach to activity and estates modelling
Building on the Out of Hospital Delivery Strategy, a process is being undertaken to model the
type and volume of activity that WL CCG will take out of hospital settings over the next 5
years. In the new model care, activity will be distributed between settings in a different way
with each setting in the new model being apportioned a certain volume of activity until the
predicted 25-30% increase in demand is accommodated. Our approach to activity and
estates modelling is shown in figure 13 below:
Figure 13: Activity and estates methodology
Page 39
Case for
change and
new model of
care - activity
moving into
OOH settings
Activity
modelling distribution of
activity between
4 OOH settings
(by 17/18)
Estates modelling – analysing the existing estate and developing
estate plans and hub pipeline
Total space
required >
existing
estate
baseline
Apply
Threshold
criteria >
long list of
potential
hub sites
Apply
Prioritisation
criteria > Hub
Pipeline and £
implications
Hubs
Assumption:
15-20% GP
volume into
hubs
Total space
required >
existing
estate
baseline
25-30%
increase
in
demand
Increase in
activity: GP
& Network
and Hub
settings
Condition
and
utilisation
analysis
Estate plans:
As Is;
Refurbish;
Reprovide;
Collocate
GP
Practices
and
Networks
Clinicians and officers from across WL CCG and NHS NW London have been engaged in the
process shown above. In particular, stakeholder involvement has been necessary in the
development of the key assumptions which has been applied in the activity and estates
modelling. The assumptions help ensure the modelling accurately reflects the local
environment and WL CCG new model of out of hospital care. Whilst all NWL CCGs are
moving in a consistent direction to support the Shaping a Healthier Future agenda, we need
to incorporate local demographics and initiatives into the modelling to ensure assumptions
within specific OOH service areas match the reality of WL CCG’s approach.
The key assumptions for West London are summarised below:
Page 40
Figure 14: Key assumptions WL CCG
Service
Assumption
Value
TOTAL
GIA (North and South locality)
GIA (Primary Care)
List size 12/13
GP appts per patient per annum
PC
Nursing/AHP appts per patient per annum
4,124
2,088
226,419
4.4
2.9
% GP practice to go into hub setting
20%
% network activity to be done in a hub
50%
% GP core &Ext/nursing activity in hubs
0%
Out of hours activity
-
% out of hours activity in hubs
0%
GIA
12/13 SUS baseline activity
464
153,150
CCG QIPP baseline activity
FAM baseline activity
OP
165,977
Reduction from referral management
7%
Reduction from FA:FU ratio improvement
0%
Activity reduction (ICP)
0%
OP activity to be re-provisioned
54,562
% requiring high level of diagnostics
50%
% low diagnostic OP activity in hubs
100%
% high diagnostic OP activity in hubs
100%
GIA
Number of GPs
Minor surgery
-
58
137
% of GPs performing minor surgical procedures
25%
% of msps in hubs
60%
Day case minor surgery activity 2012/13
14,142
% of day case in PC setting
0%
% of day cases in hubs
100%
Page 41
Service
Mental health
Reactive intervention
Proactive
intervention
Integrated nursing
Assumption
Value
GIA
116
Community Mental Health contacts 12/13
5,531
Assumed shift to primary care
50%
% shifting settings activity in hubs
80%
IAPT 12/13 Population Demographic
20,604
% IAPT activity in hubs
50%
Memory service activity 12/13
1,474
Scaling factor to include other dementia services
0%
% memory service activity in hubs
100%
Community - 1ST CAMHS
-
Community - FUP CAMHS
-
% CAMHS activity in hubs
0%
GIA
-
Total 17/18 reactive intervention wtes
-
% reactive interventions wtes office based
0%
GIA
296
17/18 LA/H&WB headcount
313
Total specialist nurse WTEs
75
Total district nurse WTEs
-
Total school nurse WTEs
-
CCG specific activity 1
Rehab
GIA
46
CCG specific activity 2
Physio
GIA
46
CCG specific activity 3
AHP
GIA
139
CCG specific activity 4
Other (CCG specific)
-
GIA
Teach/Education
GIA
418
CCG specific activity 5
Pharmacy
GIA
139
CCG specific activity 6
Dentist
GIA
-
CCG specific activity 7
blank7
GIA
-
CCG specific activity 8
blank8
GIA
-
Page 42
Figure 15 below summarises the activity modelling for West London. It shows how we expect
the volume of out of hospital activity to change and the distribution of this activity across each
out of hospital setting by 2017/18. In our modelling a significant proportion of out of hospital
activity is delivered by new hub settings by 2017/18. The activity assumptions underpinning
this rich picture, also underpin our estates analysis.
Figure 15: Volume of out of hospital activity and distribution across out of hospital
settings
NOW
+
FUTURE (17/18)
+
+
+
OUTPATIENT
+
Pathway Redesign
Outpatient reprovision
PRIMARY CARE
Pathway redesign to bring outpatients into primary care along with
outpatient reprovision in out of hospital setting
Hub based GP
practices
270,000 LIST
Networked
Services
PROACTIVE - ICP
Existing GP practices
Early Discharge
Rapid Response
INTEGRATED
Reactive intervention including Rapid Response, Intermediate
Care, Step up/down, Early Discharge teams,
NURSING
Proactive appointments
Care Planning
Proactive appointments
MDTs
Case Management base
Proactive interventions including Care Planning, Case Management, LTC/
ACSCs, Falls prevention, Risk Stratification, MDT meetings and Integrated Care
REACTIVE
INTERVENTIONS
Core/Extended Primary Care including LES/DES/LIS services &
Practice Nursing. Some practices (~20% to be relocated into hubs),
and some services to be shared across networks.
Self Care
Care Planning
Rapid Response
Intermediate Care
(Specialist Nursing)
(Practice Nursing)
(District Nursing)
COMMUNITY
Integrated nursing, combining and growing nursing role beyond
practice/district/specialist/rapid response
% Physio
% Therapies
% Podiatry
Involved in MDTs
AHPs such as Physio, Therapies, Podiatry to be bought into
MDTs for LTC and proactive care. Some community based
services relocated into hub settings
MH
Services remain in
community setting
Shifting settings of care brings some MH patients back into
primary care setting (with GP or PCLN). Also more access to
IAPT via hubs/networks.
Shifting Settings, IAPT
IAPT
Shifting Settings, IAPT
The local estate requires sufficient and suitable space at each setting to accommodate this
activity. It is recognised that additional out of hospital activity might require additional
space so, given the lead in time for estate development, an early focus is being given to
the estimation of future space requirements.
In this document, we concentrate on ascertaining the space requirements for GP
practices and Hubs. Detailed estates modelling has then been undertaken to generate
activity estimates which are then translated into space requirements. A number of
assumptions were developed and signed off by NHS PS to support estates space modelling,
including:
Page 43





Standard rooms sizes for a variety of rooms types, based on Department of Health
guidance;
Scaling factors to add an appropriate amount of supporting space (reception and
waiting areas etc.) to the different treatment/workforce room types;
A scaling factor of 1.45 to convert net internal areas into gross internal areas
(including engineering, communications and circulation);
Appointment lengths for different service types to enable the “throughput” of a given
space to be estimated; and
Guideline targets of 80% utilisation during core hours (weekdays 9-5) and 50% during
extended hours (weekdays 8-9 & 5-8, weekends 9-5), which translate into an
expected 76 hours of patient treatment time per room per week.
This work has been completed as two separate workstreams with one workstream evaluating
the GP estate and the other, hub estates. The existing GP estate has been examined to
determine how much (if any) of the additional activity this estate can absorb. The modelling
activity in this stream support the development of conclusions about the way in which existing
estate might be used or upgraded. In a parallel workstream, we have been modelling hub
estate requirements to ascertain whether there is existing NHS estate that can meet this
requirement, whether additional hub space is required and at which potential sites we might
develop hub space.
A key aim of the Out of Hospital Strategy is to bring Better Care, Closer to home, so the
space estimates for hubs have been split into locality requirements based on population size
and the prevalent care needs in each locality. This will also help ensure that Hubs are
provided at a scale appropriate to each locality. The activity and estates modelling will
interrogate the suitability of the two proposed site. By the end of this process, we will have a
detailed understanding of the proposals for the existing GP estate and the pipeline for the
proposed hub estate.
Current proposals to develop a hub in St Mary’s will likely to have implications for the north
locality hub. The proximity of the proposed north hubs to St Marys means there is a potential
for overlapping catchment areas, and a significant price differential for the delivery of similar
services. The service specification for St Mary and the activity volumes which will be
estimates based on the outputs of the activity modelling being undertaken across the OOH
Hub Programme will have to be considered within the context of the north locality hubs in
West London CCG. Work is ongoing to understand the St Mary’s hub requirements.
The next step will be to produce a PID and Outline Business Case for each of these sites.
This process will include more detailed analysis (of financial affordability and accessibility)
and the development of service specifications that are relevant to local needs and can
demonstrate a beneficial model of care.
Page 44
6. Existing estate evaluation – West London
6.1. The need to examine the existing estate
The existing GP estate has been examined to determine how much (if any) of the additional
activity this estate can absorb. This leads to conclusions about the way in which existing
estate might be used or upgraded. It also helps us understand if (and if so where) additional
estate is required – some of which could be provided by hubs.
West London CCG has gathered estates data for publicly owned buildings (across the NHS,
its providers and local authorities) across the CCG / borough area. This data covers the size,
location and assessment of condition and utilisation for all existing clinical and office
premises. There are 69 buildings in the estates baseline for CL CCG comprising:


54 GP practices; and
31 other properties.27
There are three main drivers behind the development of the local GP estate:

The need to deliver West London’s new model of out of hospital care - enhanced out
of hospital services delivered as Whole Systems Integrated Care;

The need to meet increasing expectations of quality in primary care – patient
expectations, NHS England expectations, CQC expectations, and;

The need to improve the quality of GP estate, which is currently poor in some areas.
The figure below expands upon each of these in turn.
Figure16: Drivers of estates development
Transformations
needed to deliver
OOH
 CCGs’ Out of Hospital Delivery Strategies are clear about the growing role for general practice in
delivering both accessible and integrated care
 This includes national moves towards 7-day a week working and the changes required to deliver
whole systems integrated care
 This will entail transformations in primary care, which can be supported by investment plans
Increasing
expectations of
quality in
primary care
 NHS England are planning to improve the quality of primary care in London through targeted
interventions in the bottom 10% of practices
 This will be based on a combination of GPOS, estates, prescribing, complaints and other data
 After support has been provided, the process may end in the dispersal of poorly performing practices
 This means CCGs and NHSE need to manage this process
Higher
requirements of
the quality of
practice estate
 Where practices are housed in poor quality buildings, or buildings not accessible to disabled patients
(DDA access), CQC may not register them
 This will result in NHS England terminating the practice contract, unless a solution can be found to rehouse the practice
 This means CCGs could work to support practices in poor buildings, if this supports the wider
transformations they are seeking
These drivers have four principal implications for the GP estate:
27
Including NHS, LA/PS, potential hub sites and other - health centres, head office and
community provider owned estates,
Page 45

Increased activity in out of hospital settings – creating the need for additional space
which will need to be accommodated in existing and extended GP practices.

Practices may be managed by NHS England for quality reasons – at which point
a practice patient list and delivery activity may need to be re-distributed to existing
and extended GP practices.

In some cases the quality of the estate will fall below the standards expected
therefore the condition of this estate will need to be improved. This will mean refurbishing some of the existing estate, creating a financial challenge (as opposed to
a capacity challenge).

In some cases improving the existing estate will not achieve our objectives or
represent best value. This will mean we need to re-house practices in estate that
cannot be improved in hubs or in new estate.
6.2 Approach to estates evaluation
The process we have gone through has four key stages – estimating the additional volume of
activity in primary care as a result of the new model of care, estimating the gross space
requirement, quantifying the existing space available and estimating the new space needed.
We are focusing on the use of existing space wherever possible and only when this is fully
utilised, on increasing the capacity of the estate in West London.
At this stage, we have focused on ensuring there is capacity for OOH services and that the
estate is fit-for-purpose, as the quality expectations of NHS England are still being
developed.
In developing our plans we have adhered to the same principles as those used in the
development of plans for hub estate - we will ensure that space is well used and configured
in a way that supports the effective transformation of out of hospital care. We have also where relevant – applied the same assumptions as those used by the hub workstream for
example opening hours, ways of working, GPs offering OOH services.
The approach is outlined in Figure 17 below:
Figure 17: Approach to estates evaluation
Gross space
requirement
Volume
•
Additional OOH
activity
Practices in
poor quality
estate needing
re-furbishment
Practices in
poor quality
estate needing
re-housing
6.3
Volume of OOH activity
to be delivered in primary
care
Includes core primary
care, minor surgery,
integrated care, and MH
•
•
•
Practices surveyed as
condition D (needing
improvement)
•
Practices surveyed as
condition CX or DX
(necessary
improvements not
possible)
•
Existing space
available
Gross space requirement
Assumptions about room
size and utilisation
consistent with hub
development
•
•
Current size of practices
needing re-housing
•
N/A – space already
exists
Net space needed
Spare capacity is based
on current capacity below
target utilisation rate
Activity accommodated in
spare capacity if possible
•
Activity that cannot be
accommodated in
existing estate
•
N/A
•
N/A
•
Hubs offer space for
assumed number of
practices
Practices needing rehousing accommodated
in hubs if possible
•
Activity that cannot be
accommodated in
existing estate
•
•
Analysis of the existing estate in West London
Page 46
The condition, capabilities and utilisation of the existing estate in West London is mixed, with
surveys suggesting that some buildings do not each relevant standards, but also that there is
some capacity for the existing estate to absorb increased demand and to deliver the CCG’s
new model of care.
The sections below outline the physical condition, accessibility, utilisation and scale of the
non-acute estate in West London, compared with the relevant standards. It is split into
primary care estate (for delivery of GP services) and all other out of hospital estate.
6.3.1 Standards for estate
The expectations of our estate are based on ensuring that we have fit-for-purpose buildings
that are well utilised, in line with our standards of care and expectations of development
across out of hospital care.
This means:
 Buildings must be of an acceptable physical condition.

Buildings must offer acceptable accessibility, especially for disabled patients.

Buildings must be well-utilised, defined at being occupied 80% of the time during
core hours and 50% of the time during non-core hours (evenings and weekends).
6.3.2 Condition of existing GP estate
Physical condition
We have surveyed 44 of the 54 practices in West London for condition.
Extrapolating to all the practices in West London, we estimate 28–49 have a physical
condition rating of A, B or C. Approximately 2–7 are rated D (unacceptable), meaning they
require refurbishment. In addition, 3–19 are rated CX or DX, meaning improvement of the
current building is not possible; these practices need re-building or re-housing elsewhere.
This means that due to their condition, 2–7 practices may need re-furbishing, and 3–19
may need re-housing.
Accessibility
We have surveyed 18 of the 54 practices in West London for accessibility.
Extrapolating to all the practices in West London, we estimate 36–47 have a rating of A, B or
C for accessibility. Between 1 and 4 are rated D (unacceptable), meaning they require
adaptations; in addition, 6–14 are rated CX or DX, requiring re-building or re-housing
elsewhere.
This means that due to their accessibility, 1–4 practices may need adaptations and
improvements, and 6–14 may need re-housing.
Utilisation
Across West London, utilisation of the primary care estate is good, averaging 58%
(compared with a North West London average of 55%).
However, this is below the target utilisation of 66% (80% during core hours and 50% during
extended hours).
This suggests that additional capacity may be released if practices improve their
utilisation.
Page 47
6.3.3
Other out of hospital estate
The non-GP estate in West London includes health centres, hospital sites, local authority
sites and other clinics.
Physical condition
We have surveyed 15 of the 31 buildings in West London for condition.
All 15 had a condition rating of A, B or C, meaning all are suitable for delivering some out
of hospital services. These are not necessarily hub sites: this is discussed further below.
Accessibility
We have surveyed three of the buildings in West London for accessibility. These are all rated
DX, meaning it requires significant re-building.
Utilisation
Across West London, utilisation of the estate is good, averaging 57% (compared with a North
West London average of 55%).
However, the estate does fall below the target utilisation of 66% (80% during core hours and
50% during extended hours).
This suggests that additional capacity may be released if buildings improve their
utilisation.
6.4 Absorbing out of hospital activity in primary care
As described above, GP estate in West London will need development in order to support the
delivery of transformed care. Our plans for out of hospital care suggest that up to 420,000
appointments will be moved into primary care and networks over the next five years
(excluding activity moved to hubs). The additional volume from new services may mean
that up to 2,700 m2 of space may be required across West London.
Based on the utilisation assumptions outlined above, our analysis of the current GP estate
suggests there is approximately 1,500 m2 of spare capacity across West London that
could be released if primary care operated the level of utilisation expected across North West
London. This would accommodate most OOH activity.
There is a remaining requirement for 1,200 m2 to be developed, which will form the basis of
further planning for the non-hub estate.
Page 48
Figure 18: Approach to estates evaluation
Space required, ‘000 m2
1
420k OOH appts
in primary care1
2,700 m2
2.7
2
Capacity from
improved
utilisation2
1,500 m2
3
Additional space
needed for OOH
1,200 m2
1.5
1.2
Space
requirement for
OOH care
Spare GP
capacity
Space
requirement for
re-housing / rebuilding existing
practices
Source: S&T analysis. SSDP activity model, NWL estates surveys
1 GP element of assumed OOH activity (primarily integrated care services), which is split between GPs and hubs.
2 Space within a locality available for OOH activity if utilisation increases to 80% during core hours and 50% during non-core hours
6.5 Improving the condition of general practice estate
In developing the estate, we are focusing on the estate that is not of adequate condition or
accessibility; the quality of individual practitioners is the domain of NHS England.
As described above, we have a number of practices that require re-housing or re-building.
This means we need to re-provide space for 8–12 practices, or 1,000–1,500 m2.28 This will
replace existing, poor quality, estate. In addition, 2–4 practices (200–500 m2) will been
refurbishing or adapting to meet standards.
In addition, our plans for hubs include 1,300 m2 of space for practices to move in, which will
be able to accommodate some of those practices currently in premises that do not meet
estates standards. These practices will be able to work within a holistic health and care
facility, and benefit from co-location with experts and supporting equipment. Initial estimates
suggest that 5–8 of the practices needing re-housing may be close enough to a hub to
consider using it, meaning we may be able to use 600–1,000 m2 for such practices.
Accommodating the remaining activity will require expansion of key, strategic practices and
other buildings. We will invest in these to re-provide 400–600 m2 across West London. In
addition, 200–500 m2 will need to be refurbished or changed to meet standards. The
approximate implications of this are outlined below, but will be subject to more detailed
business case development for each site.
28
Based on practices moving to the same size as expected of practices in hubs, with 30 m2
per 1,000 list size.
Page 49
Figure 19: Space requirement in West London
Space required, ‘000 m2
1
8–12 practices
need re-housing /
re-building
1,000 – 1,500 m2
2
Hub space for rehousing1
600 – 1,000 m2
5
Additional space
needed
400 – 600 m2
2–4 practices
need refurbishing
200 – 500 m2
0.6 – 1.0
1.0 – 1.5
Space
requirement for
re-housing / rebuilding existing
practices
Hub capacity for
re-housing
0.4 – 0.6
0.2 – 0.5
Additional space
needed
Space needing
re-furbishing
Source: S&T analysis. SSDP activity model, NWL estates surveys
1 Space available near practices needing re-housing
The estates analysis has implications for wider NHS England investment in the primary care
estate, both for GP practices and hubs. Significant investment is necessary to bring the
premises in West London that need improvement up to a suitable standard and the NHS in
NW London has committed to capital investment.
Some of this investment will be considered in business cases for hubs, but wider investment
in the GP estate will be addressed through the primary care development work within the
Shaping a healthier future programme. In addition some consolidation will be necessary with
the aim of delivering, over time, fewer higher quality practice sites in higher quality premises.
Some of this can be achieved by the development of out of hospital hubs which provide an
opportunity for improved premises and consolidation.
Further analysis will develop these plans further, to show how we can maximise the benefit of
estate changes through co-location and other new ways of working. However, all estate that
receives investment or development will adhere to the same ways of working as all other
providers. This means:


Integrated ways of working, including shared systems, network working, integration
with other services, and inter-referral.
Provision of relevant access and opening hours, including telephone/virtual
access to consultations and extended opening hours.
* An updated capital estimate is being prepared
Refurbishment or re-building of practices may also have revenue implications; where
practices move or have their estate refurbished there is the potential for rent increases, which
could also impact rent reimbursement arrangements. The financial implications will need to
be calculated on a practice-by-practice basis; however, we have agreed with NHS England
that this rent reimbursement may be jointly funded. NHS England will retain responsibility for
rental increases associated with bringing buildings up to the minimum statutory standards.
CCGs may need to contribute where their decisions about practice moves (e.g., co-locations
in a hub) create additional rental pressures. To minimise the impact on NHS England, we will
seek to ensure space is fully used and shared between providers. Where there is a
significant impact, this will be discussed on a case-by-case basis with NHS England to agree
an equitable settlement.
Page 50
In the coming months, these plans will be developed further, with detailed analysis of the
requirements within each locality to provide an understanding of which practice could be colocated, which can be re-housed, which need re-furbishing and which might move to hubs.
Page 51
7. Hub space requirements – West London
The process that we have gone through to develop detailed estate plans for the hubs has
been developed working closely with NHS Property Services and WL CCG officers and
Executive Management Team. The assumptions implicit in the process are:
o
o
o
There will be one hub per locality unless the activity analysis suggests another
approach is sensible
Existing sites will be utilised before building any new sites
NHS property will be prioritised above other public sector or commercial properties
7.1 Activity modelling
To estimate the scale of future activity in hubs, assumptions have been made for each
service likely to be delivered in or from a hub. These assumptions are underpinned by data
on existing and planned arrangements for care delivery. The following were identified through
discussion with the CCG as providing significant activity or space requirements for out of
hospital care and in particular hubs:
Figure 20: Activity modelling, key service categories
Themes to model
Information required
Outpatient
Re-provision
Top Down and Bottom Up QIPP plans for the volume of
Outpatient activity to move to community setting
Primary Care
Primary Care Estates strategy: % of premises to receive
investment, % of estates to move to hubs
Minor Surgery
Clarification on levels of Minor Surgery to be provided in hub
setting and likely volumes
Proactive Integrated
Teams
Current activity levels and the future vision of the following:
Putting Patients First, Case Management, ACSC conditions,
Falls Prevention, Whole Systems
Reactive Integrated
Teams
Current activity levels and the future vision of the following:
Rapid Response, Intermediate Care beds, Early Discharge,
Rehabilitation & Re-ablement
Mental health – shifting
settings of care
% of activity likely to move from Community Health Care into
Primary Care, Dementia pathways, current mental health
estates strategy.
Moving existing
Community Services
e.g. Physiotherapy, OT, to be co-located, or based in more
suitable premises
Moving existing Mental
Health Services
e.g. CAHMS to be co-located, or based in more suitable
premises
Training & Education
Total activity expected (i.e. user of rooms) and distribution
across Hubs. Potential to share space.
Community voluntary
services
e.g. Open Age, WAND, Living Well
Commercial space
e.g. Pharmacy
Local Authority
Shared working space as part of Integrated working
Page 52
Activity is driven by GP appointments, outpatient appointments and community services (long
term conditions and elderly care) in particular. Many services are assumed to be equally
distributed across the CCG, although some localities have a specific focus because of their
commissioning arrangements or prevalence data. A summary of the methodology for activity
modelling can be found in appendix 4.
The figure below summarises the volume of activity to be delivered within or from hubs
broken down by service and locality. The change in the volume of activity from the current
2013/14 baseline is also shown.
Figure 21: OOH Activity Split for Hubs and Localities
WEST LONDON - ACTIVITY (List size: 226,419)
Activity moving into Hub
Type
17/18 activity
North
South
Total Hub
245,000
178,000
423,000
Primary care
appts
1,841,000
Outpatients
appts
55,000
26,000
29,000
55,000
Minor surgery
procs
3,000
1,000
1,000
2,000
Mental health
appts
20,000
7,000
5,000
12,000
Reactive intervention
0
0
0
0
Proactive intervention
0
0
0
0
Integrated nursing
0
0
0
0
Diagnostics
0
0
0
0
Additional (CCG specific)
0
0
0
0
2,121,000
352,000
254,000
605,000
* The additional activity category includes rehabilitation teams, rehab teams, pharmacy and space for
teaching/education
7.2 Hub space requirements
It is expected that hubs will need to provide space for both community services and primary
care (GP) services. We have therefore incorporated these space requirements into our
analysis acknowledging that some of the GPs moving into hubs will be moving from another
practice elsewhere in the borough.
Data on the activity and workforce requirements in each locality has been translated into a
space requirement in terms of the gross internal floor area (GIFA m2) that we estimate will
be required. Detailed of the methodology for translating activity into space requirement are
included in appendix 5.
Assumptions are derived from estimated appointment numbers based on the total West
London list size as we will not know until the latter stages of this process, which surgeries will
be moving into hubs. Similarly, assumptions about the total space community services will
Page 53
require in hubs is based on both services currently delivered and new services, and may
require in some instances that community services to move from another location in the
borough to be more integrated in a hub.
A key aim of the Out of Hospital Strategy is to bring Better Care, Closer to home, so the
space estimates have been split into locality requirements based on population size and the
prevalence of different care needs. This ensures that Hubs are provided at a scale
appropriate to each locality.
Figure 22: Hub activity and space requirement for West London CCG
WEST LONDON - SPACE (GIA/m2)
Activity moving into Hub
Type
North
South
Total
m2
Total #
rooms
Primary care
appts
1,211
877
2,088
36
Outpatients
appts
218
246
464
8
Minor surgery
procs
34
24
58
1
Mental health
appts
65
51
116
5
Reactive intervention
-
-
-
-
Proactive intervention
198
98
296
8
Integrated nursing
197
117
313
3
Diagnostics
-
-
-
1
Additional (CCG specific)
467
322
789
2,389
1,735
4,124
13
75
As a result, it is estimated that in total, West London CCG will require approximately
4,124m2 of space for hub services across localities in West London (including GP and
existing community provided services).
The next section will focus on these Hub space requirements, considering how any underutilised space in existing Health Centres may be better used and evaluating the range of
possible sites for the additional Hub space required.
Key points:

Taking a range of plus or minus 10%, hub space of between 3,700 and 4,500 m2 is
required across West London.

Proportionally splitting the requirements (using population and prevalence data)
results in space requirements in the region of 2,389m2 in the North Locality and
1,735m2 in the South Locality. When finding suitable estates that can accommodate
this space, space estimates are used: 2,000-3,000m2 in the north locality and 1,4002,000m2 in the south locality.
Page 54
8 Estates modelling
This chapter describes the threshold and prioritisation criteria agreed by the NWL
Collaboration Board to assess the relative merits of different options for hubs across the
different localities. It describes how these criteria were applied to the options and the relative
assessment of each option.
As two hubs are required for the North and South locality of West London, the analysis for
both hubs will be done and reported separately in this SSDP.
8.1 Application of threshold criteria
The NWL Collaboration Board has agreed threshold and prioritisation criteria to support the
selection of appropriate Hub sites. Firstly, sites must pass the minimum “threshold” criteria:



A minimum size of 500m2 (gross internal floor area), based on an assessment of the
minimum possible size of a Hub given the proposed model
Sufficient evidence of out of hospital activity demand and patient catchment and
Sufficient available or under-utilised space to accommodate the space requirements
identified
8.1.1 Minimum size of 500m2
A review of the West London estates baseline revealed that, in the 10 of the estates in the
North locality had a gross internal floor area (GIFA) of greater than 500 m2. To ensure that a
wide range of existing and potential estates within the CCG were evaluated, pipeline
developments within the 2017/18 timescales were also added to the long list.
It should be noted that although capacity analysis is based on data from surveys, some of
this is old data (from 2007) and therefore, NHS PS has in some cases made an assessment
as to capacity and condition rating based on up to date working knowledge.
Estates in the north and south locality which met the minimum size of 500m2 are listed below.
Full details of properties considered in this assessment are in appendix 6. A number of
pipeline estates were also considered for the north and south locality hubs. In theory, these
estates could be considered candidates for the hub sites many of these would potentially
meet the hub space requirement. However, all estates in the pipeline are in the order of 3-5
years away from completion which means they do not provide an imminent solution for the
provision of out of hospital services. As such, none of the pipeline developments will be taken
into the threshold criteria at this stage. The list of pipeline estates considered is also in
appendix 6.
Figure 23 – Long list of possible hub estate with GIFA >=500 m2
North locality
Postcode
Name
W10 4LY
Queen Park Health Centre – 3 GP practices
W2 5EH
Fluxman Harrow Road Health Centre
W2 1NR
West Two Health Centre
Tenure
GIFA (m2)
CLCH F/H
842
n/a
945
Owned
802
Page 55
W11 1PA
Colville Health Centre - 2 GP practices
CLCH - LH
> 500
W10 6PU
Kingsbridge Road LDU*
NHS PS FH
593
W10 6DZ
St Charles Centre for Health and Wellbeing
NHS PS -
W10 6NX
St Quintin Avenue Health Centre (includes North
Kensington Medical Centre)
W10 4RE
Half Penny Steps Health Centre
W10 6DL
Princess Louise Nursing Home
W9 3RN
Flats A, B AND C 291 Harrow Road
19,487
FH
NHS PS FH
545
501
n/a
NHS PS
2577
NHS PS FH
621
South locality
Postcode
Name
Tenure
GIFA (m2)
Part Leased
581
NHSPS
Leased
550
SW5 9AD
Earls Court Medical Centre
W14 8HW
Kensington Park Medical Centre
SW5 0PT
Earls Court Health and Wellbeing Centre
NHS PS LH
728
SW7 4HJ
Emperor’s Gate Health Centre
NHS PS LH
810
SW3 5RR
Violet Melchett Health Centre
CLCH - LH
1848
SW10 0UD
Worlds End Health Centre
CLCH - FH
1073
The Abingdon Health Centre
NHSPS
Leased
643
SW10 9EL
Chelsea Chambers
CNWL
510*
SW3 2EE
Chelsea Town Hall
LA
n/a
Niddry Lodge, Kensington Town Hall
LA
1,971
New Marlborough School
LA
3,000
W8 6EG
W8 7NX
SW3 3AP
The expected future demand for each locality has been calculated and used to generate the
size requirement for each locality hub. In the North locality, it is estimated that 2,0003,000m2 of space is required for hub activity. In the South locality, is estimated that a hub
space of 1,400-2,000m2 is required.
Estates that had met the minimum size criteria were then matched against the space
requirements for each locality. Where estates did not currently meet the space requirement,
we considered the potential for the estate to be expanded to meet the requirement. Estates
that were considered to either currently meet the space requirement for the locality hub or
that could potentially be expanded to meet the hub space were taken into the threshold
criteria exercise.
Page 56
Four estates each in the North and South were taken into the threshold criteria exercise:
North locality potential hubs




St Charles’ Centre for Health and Wellbeing
Princess Louise Nursing Home
Queens Park Health Centre
St Quintin Avenue Health Centre
South locality potential hubs





Violet Melchett Health Centre
Worlds End Health Centre
Chelsea Town Hall
Niddry Lodge, Kensington Town Hall
New Marlborough School
8.1.2 Sufficient Demand
The first threshold criteria assessed whether there was sufficient demand level in each
locality to support the proposed development of a hub. The activity modelling is designed
based on 80% utilisation in core hours and 40% utilisation in non-core hours as agreed with
NHS Property Services. Sensitivity analysis data on the data shows that 10% less utilisation
would translate into approximately 250m2 more space requirement.
The activity modelling thus shows that there is sufficient activity in both the north and south
locality to support a hub in each area. As such, all potential hub options will be considered to
pass this criterion.
8.1.3 Commitment to space utilisation
This criterion assesses where the proposed overall configuration fully makes use of all spare
capacity across the CCG before committing to additional investment. To apply this criterion,
we will be looking to prioritise NHS and LA estates over commercial properties.
In the north locality, all four potential hub sites are owned either by NHS PS or CLCH and as
such will all pass this criterion. In the south locality, all potential estates are either owned by
CLCH or the local authority and as such would be considered to pass this criterion.
8.1.4 Condition of estate
This criterion assesses whether the estate under consideration either meets or can be
improved to meet minimum standard. Estates with a physical conditions rating below C (that
is CX, D or DX) will be deemed to fail this criterion. In the north locality, none of the potential
hub estates had a physical condition rating that was lower than a C and therefore all passed
this criterion.
Of the fiver estates in the south locality, two had ratings that were above a C and as such
passed the criterion. The remaining three estates, Niddry Lodge, Chelsea Town hall and New
Marlborough School did not have physical condition ratings allocated to them in the estates
survey. Niddry Lodge has anecdotally been assigned a C rating based on the fact that the
estate has recently been refurbished and will at the minimum have a C-grade rating. New
Marlborough School will be a new development and will also be in good condition. Chelsea
Town Hall has also been anecdotally assigned a C rating based on knowledge of the estate.
On this basis, all estates in the south locality will be deemed to pass this criterion.
Page 57
Figure 24 – Six facet ratings of short listed estates (north and south locality)
North locality
6-FACET RATING
Postcode
W10 4LY
W10 6DZ
W10 6NX
W10 6DL
Name
Tenure
GIFA
(m2)
Queens Park
Health Centre
CLCH
842
– 3 GP
F/H
practices
St Charles
Centre for
NHS PS 19487
Health and
FH
Wellbeing
St Quintin
Avenue Health
Centre
(includes
NHS PS 545
North
FH
Kensington
Medical
Centre)
Princess
Louise
NHS
2577
Nursing
PS
Home
1) Physical
2) Statutory
4)
6)
Condition
3) Space
5)
compliance
Functional
Environmental
Rating
utilisation
Quality
rating (H&S
Suitability
management
(Fabric &
rating
rating
/ Fire)
Rating
rating
M&E)
Pass/Fail
B
B
F
B
B
B
Pass
B
B
U
B
B
C
Pass
B
B
U
C
B
C
Pass
B
B
F
B
B
B
Pass
South locality
6 – FACET RATING
Postcode
SW3 5RR
SW10 0UD
SW3 2EE
W8 7NX
SW3 3AP
Name
Tenure
Violet Melchett
Health Centre
Worlds End
Health Centre
Chelsea Town
Hall
Niddry Lodge,
Kensington
Town Hall
New
Marlborough
School
CLCH LH
CLCH FH
GIFA
(m2)
1) Physical
2) Statutory
4)
Condition
3) Space
5)
6) Environmental Pass/Fail
compliance
Functional
Rating
utilisation
Quality
management
rating (H&S
Suitability
(Fabric &
rating
rating
rating
/ Fire)
Rating
M&E)
1848
C
B
F
B
B
C
Pass
1073
B
B
F
B
B
B
Pass
LA
TBC
TBC
TBC
TBC
TBC
TBC
TBC
Pass
LA
1,971
n/a*
n/a
n/a
n/a
n/a
n/a
Pass
LA
3,000
LA
3,000
n/a
n/a
n/a
Pass
n/a
8.1.5 Scope for expansion
Estates will be considered to pass this criterion if the estate being either currently or
potentially capable of accommodating additional services either through expansion or
improve utilisation. In the north locality, the St Quintin and Queens Park estates fall below the
hub space requirement and will need to be expanded to meet the required space for a hub.
Of the two, St Quintin is currently underutilised (based on space utilisation ratings) which
means that a smaller amount of space will need to be built to meet this hub space. From the
space utilisation ratings, Queens Park is fully utilised. However, as some of the services
being delivered in the health centre will be delivered in the hub, this will also reduce the
amount of additional space to be developed.
Page 58
In the case of Princess Louise Nursing Home, whilst the estate falls within the required hub
space, the space utilisation rating indicates the building is fully utilised. Freeing up space for
the hub will involve re-commissioning of nursing home services which will be extremely
difficult. As such, this property will be considered to fail on this criterion.
To this end, three estates in the north locality will be taken into the prioritisation exercise:



St Charles’ Centre for Health and Wellbeing
Queens Park Health Centre
St Quintin Avenue Health Centre
In the south locality, three of the five estates currently meet the space requirement for hubs.
The World’s End Health Centre has additional land space in the car park and can thus be
expanded to increase the current size and meet the space requirement for the southern hub.
The Chelsea Town Hall is a Grade 1/2 listed building and as such there might be limitations
to the extent of structural changes that can be made to the building to support the delivery of
modern medical services. The Chelsea Town Hall will consequently be considered to fail this
criterion and will not be taken into the prioritisation exercise.
Three estates in the south locality will be taken into the prioritisation exercise:




Violet Melchett Health Centre
Worlds End Health Centre
Niddry Lodge, Kensington Town Hall
New Marlborough School
8.2 Application of prioritisation criteria
The NWL Collaboration Board also agreed “prioritisation criteria” to support the selection
of appropriate Hub sites. The West London sites have been assessed against the
prioritisation criteria (public transport accessibility and geographical proximity to areas of
high population density and deprivation). Initial results indicate that two of the proposed hub
sites in the south locality score highly and should be considered as suitable sites to enable
the delivery of Better Care, Closer to Home. In the north locality, the St Charles Centre for
Health and Well Being is emerging as the preferred site with St Quintin Health Centre site
following closely as the 2nd option for a hub site.
Below we show the results against the prioritisation criteria. Full details of the prioritisation
exercise can be found in Appendix 7.
8.2.1 Achieving our Out of Hospital Strategy
This criterion judges whether a site fits with the Out of Hospital Delivery. Estates where hub
type services were such as GP services were currently being provided were scored more
highly than others. All potential hubs scored positively on this criterion.
In the north locality, St Charles scored the highest score (++) of the three potential sites as
this estate currently provides services that are closest to what a hub will be expected to
deliver.
In the south locality, all sites except Niddry Lodge and New Marlborough School were given
a ‘+’ score as they provide GP services. Niddry Lodge and New Marlborough School were
given a neutral score as it is currently an office space that will need to be re-configured to
deliver primary care services.
8.2.2 Value for money
Page 59
This criterion judges whether the proposed capital and revenue expenditure on the proposed
hub site are affordable to all parties affected (including providers, CCG and NHSE. Estates
that required lower levels of investment were scored higher than those that required higher
levels of investment to deliver hub services. Estimates for the cost of various levels of
refurbishments and new builds were supplied by NHS Property Services and Turner and
Townsend to support the quantification of estate investment required.
In the north locality, both Queens Park Health Centre and St Quintin Avenue Health Centre
would require higher investments to deliver hub services than St Charles Centre for Health
and Wellbeing. In the south locality, both the Violet Melchett Health Centre and the World
End Health Centre required more investment of the three options. In the case of Violet
Melchett, this is because a proportion of current services delivered in the estate will have to
be re-provisioned to free up the space for hub services. For World’s End, additional space
will need to be built up on the site (this land is available to do this) to co-locate current
services with new hub services that will be delivered from that site.
8.2.3 Accessibility
This criterion evaluates the accessibility of the site by public transport and how well the site
meets DDA requirements. Accessibility by public transport has been assessed using a
method used in UK transport planning to assess the access level of geographical areas to
public transport – the public transport accessibility level (PTAL). A PTAL score of 1a
indicates extremely poor access to the location by public transport, and a PTAL of 6b
indicates excellent access by public transport. The Disability Discrimination Act rating from
the estates baseline is used as a measure of access by persons with a disability.
In the north locality, all three sites have similar PTAL scores and as such have been
allocated a neutral score across the three estates. For the DDA rating, St Quintin and St
Charles both having DDA ratings of B with the Queen Park site having a C rating. In the
south locality, Niddry Lodge and New Marlborough School have the best accessibility of the
three potential estates as they are both relatively new estates, whilst Violet Melchett Health
Centre has the least favourable DDA rating of the three potential sites.
8.2.4 Commitment to space utilisation
Based on a qualitative assessment by NHS PS, estates are ranked based on their flexibility
to be adapted for different purposes. The tenure of the estate is also considered based on
the expectation that NHS estates will be utilised in favour of other public sector estates and
commercial spaces (to be considered only as a last option).
All estates in the north and south are considered flexible although the lease for Violet
Melchett expires in 2017 with no guarantee of renewal. In the north locality, St Charles and
St Quintin have the highest scores for tenure as they are both NHS PS estates. In the south
locality, Niddry Lodge and New Marlborough School both have the lowest tenure score as
although they are a local authority property, both estates are available at commercial rates.
8.2.5 Condition of estate
The suitability of an option is scored based on the number of poor quality GP premises (C or
below) that are within 0.5 miles of the hub and which could move into the potential hub is
considered here. It is assumed that it is preferred to not move GP premises with a physical
condition rating of B or above into a hub so that will score negatively.
In the north locality, potential hubs are mostly surrounded by B rated GP premises though
Queen’s Park Health Centre and St Charles have one C grade estate within their catchment
area. The same is broadly true in the south locality with potential hubs being mostly
surrounded by B grade GP premises. Violet Melchett Health Centre is however surrounded
Page 60
by two GP premises rated C. New Marlborough School is also surrounded by four GP
premises rated C.
8.2.6 Population
The population density in the area surrounding the proposed hub is considered with hubs
that cover larger populations being prioritised. Also considered is the percentage of the
population that are over 65 in the locality with a high percentage of older population scored
highly.
The CCG is fairly dense populated with the northern wards being more uniformly densely
populated than the south. Although dense, the population in the south is less uniformly
distributed across the area. The areas around all sites however are densely and as such, all
sites in the north and south locality have been allocated a ‘++’ score for population density.
The areas around also St Charles and St Quintin have a high percentage of people aged
over 65.
In the south, all four proposed sites are equally populated, with Violet Melchett also having
the highest percentage of over 65s of the three sites.
8.2.7 Deprivation
This criterion prioritises hub sites that are in areas that are more deprived. All three north
locality sites score highly for deprivation. Deprivation in the southern locality is relatively less
than in the northern wards, however of the three southern sites, the level of deprivation in the
area surrounding the World’s End site is comparable to the northern locality.
8.2.8 Overview of prioritisation scores
Below is a summary of the prioritisation scores that have been allocated to each of the sites
for each prioritisation criterion.
Figure 25 – Summary of prioritisation scores for north and south locality
Locality
North
South
OOH
DS
VFM
Queen's
Park
+
-
St
Charles
++
St
Quintin
+
-
Violet
Melchett
+
-
+
World’s
End
+
-
+
+
++
+
++
Site
Niddry
Lodge
New
Marlb
School
Access
DDA
score
Space
(Flex)
Space
(Tenure)
GPs
Pop.
+
+
+
++
+
+
++
+
++
+
+
++
-
--
+
+
+
+
+
Over
65s
Depriv.
Total
++
8+
1-
+
++
12 +
++
+
+
9+
2-
++
++
+
+
10 +
3-
+
-
++
-
+
7+
3-
+
-
-
++
-
7+
3-
+
-
++
++
Page 61
9+
1-
8.3 Site selection
The prioritisation exercise supports the identification of priority sites in each locality for further
exploration in each locality. The viability of the selected sites will be explored in further detail
in the Outline Business Case which will subsequently be developed.
Subject to agreement by the CCG, the following sites will be taken into the OBC:


In the North, we will take St Charles as our preferred option but also take St Quintin
into the OBC
In the South, we will take the Violet Melchett, World’s End Health Centre and the New
Marlborough School into the OBC
Page 62
9 West London - Hub pipeline and financial implications
9.1
Hub pipeline
The pipeline for Hubs in West London is well developed with a number of section 106
opportunities on the horizon in both the north and south locality (see Appendix XX). In the
northern hub, the St Charles site is an existing estate which emerging as the preferred hub
and will, with a moderate amount of refurbishment, enable the delivery of the Out of Hospital
Strategy (the site currently delivers services that are consistent with the hub service
specification).
In the south locality, the Earls Court site is considered as the preferred estate for the
southern hub. However, as this development will not be completed for another 5 years, an
interim solution in the south locality will be developed in the shorter term. The selected south
hub site will be developed to deliver hub services pending the completion of the Earls Court
development site.
The figure below illustrates the hub pipeline for West London CCG.
Figure 26: Hub pipeline and estimated capital costs (ECC)
In place
2014/15
Earls Court
Centre for
Health and
Wellbeing and
St Charles
ECC £0m
2015/16
2016/17
2017/18
2018/19+
St Charles
ECC £4-5m
South Hub (tbc)
ECC £~2m
Hub – Earls
Court/Local
Authority
pipeline
ECC £ tbc
(S106 funding)
ECC: Estimated Capital Cost
9.2
Total Capital Cost of the West
London CCG Pipeline = £~6-7m
Financial implications
9.2.1. Financing the hubs
High level capital estimates are outlined in figure 26 above. The financial case for out of
hospital hubs will be developed in greater detail at OBC stage. This financial case will include
a process whereby we will work through current and future service settings adopting high
Page 63
level assumptions around savings and test these. This approach is summarised in the
diagram below.
Figure 27: Developing the financial case for hubs
For Hub schemes…
Other hub services
Cost for equivalent list at A rated
premises
Hub services (excluding PC):
CCG top-up or identify funding
e.g. SIFT
GP Services for Out of Hospital
Care
Increase in GP rent (C/CX /D
/DX premises): NHSE increase
Current NHSE GP
reimbursement (including
service charges)
Current GP Costs
Future Hub costs
Determined by
m2 split
between core
GP and OOH
Draft Methodology
•
Compare current rent of given “C/CX/D/DX” GP
premises to existing “A/B” rated premises in the
CCG areas on the basis of £m2 and £ per patient
•
Include DV uplift to regularise historic rates to
expected current rates and compare the DV view
on an “A” rated new build in the CCG area
•
The difference between current rent at the
“C/CX/D/DX” and the “A” rating for a given CCG
area would be paid for by NHS England (in
proportion to Primary Care space).
•
As plans progress through the process this will
become the actual costs
•
For hubs, the cost of GP services for non-primary
care would be covered by the CCG
•
For GP only schemes, the remainder would need
to be covered by the GP
For GP only estate…
Cost for equivalent list at new build
premises
Cost for equivalent list B at rated
premises
Increase in GP rent (non C/ CX
/D /DX premises): GP top-up
Increase in GP rent (C/CX /D
/DX premises): NHSE increase
Current NHSE GP
reimbursement (including
service charges)
Current GP Costs
Future GP costs
West London CCG is estimating its capital requirement for 2014/15 and a capital return to be
sent to NHS E is now being prepared. This outlines for the financial years 14/15 and 15/16
the proposed capital estate investments by CCGs
For the avoidance of doubt, although this return has been made naming specific out of
hospital hubs and GP premises, subject to the successful development and approval of this
SSDP by the CCG, then the PIDs, OBCs and FBCs by NHS England. It is indeed possible
that different specific out of hospital HUBs and GP premises will be introduced as a result of
that process.
We expect that hub proposals are unlikely to be constrained by capital affordability provided the revenue is available to cover the annual costs of the hubs. This is because
providing that there is revenue to fund it, there are a number of alternative funding routes.
These are set out below.
Page 64
Figure 28: NHS Capital Routes
Building owner - NHS PS
Building owner - GP
Building owner - NHS
Trust
Building owner - Council
Building owner - 3rd Party
Landlord (incl. LIFT and
PFI)
Nature of investment New Build
NHS PS customer capital
from DH (note - landlord
capital is for maintaining
not enhancing)
NHSE capital grants to
pass through to GPs –
potentially limited to 66%*
NHST funds using own
capital, loans, PDC – TDA
involvement*
NHSE capital grants or
Council sourced capital
that will be recouped via a
rental charge*
NHSE grants will require a
legal charge to be attached
to the resultant asset.
Capital investment to be
sourced by landlord and
recouped through rental
charge*
Nature of investment Refurb/Fit Out
NHS PS customer capital
from DH (note - landlord
capital is for maintaining
not enhancing)
NHSE capital grants to
pass through to GPs –
potentially limited to 66%*
NHST funds using own
capital, loans, PDC – TDA
involvement*
NHSE capital grants or
NHS PS customer capital
or Council sourced capital
– both NHS PS and council
sourced capital will be
recouped via a rental
charge*
Nature of investment Movable Fittings
NHSE**
Nature of investment Equipment
NHSE** – s.t. admin IT
where CSU
NHSE**
NHSE** – s.t. GP IT and
admin IT where CSU
NHSE** – for HUB or GP
on NHST site
NHSE** – s.t. admin IT
where CSU
NHSE**
NHSE** – s.t. admin IT
where CSU
Potential for NHS PS
NHSE**
customer capital or capital
investment to be sourced
by landlord and recouped
through a rental charge*
NHSE** – s.t. admin IT
where CSU
There are a wide range of financial interdependencies, including those that result from the
funds flow within the health system, which we will need to consider at OBC stage. Savings
will largely arise from:




9.2.2
The same delivery of services as in acute, but delivered at a cheaper price point
(i.e. through lower overheads in a community setting)
A new delivery model where efficiencies are made through economies of scale e.g.
combining multiple appointments
Prevention and demand management reducing the long term cost of care through
intervening earlier, or differently;
Better access provides an economic benefit for patients in saving them time
(however, there are also risks around rising costs if access to care is easier or care
is higher quality, as demand may increase).
Rent Reimbursement
There is likely to be an increase in rent for GP premises as a result of investment in primary
care estates. Any increase in the expectation on NHS England will need to be supported by
and agreed by the NHS England London Region Primary Care Team. Rent is determined by
a formula which is primarily driven by the assessment of the District Valuer. There are 3
possible reasons for rent to increase:



Properties in poor condition being improved
Leases coming to an end
List size inflation
The rent reimbursement implications will need to be calculated on a scheme by scheme
basis; however, we have discussed with NHS England the principle of their funding increases
in rent reimbursement where existing premises do not meet the minimum required standard.
CCGs may need to contribute where GP involvement is part of the Out of Hospital strategy
resulting in additional rental pressures. To guide this process, we have agreed a series of
principles:
Page 65



NHS England will fund increases in rent due to the rising rental costs (i.e. if we do
nothing but rents on GP premised increase due to market prices)
NHS England will fund increases in rent due to the improvement of premises from “C”
rating to an acceptable condition for the delivery of primary care. Note: Properties
rated CX or below are not suitable for investment
Where relocation to improved premises is required or is proposed as the most
favourable option, NHS England will fund a proportion of increase cost equivalent to
improving the existing premises
PIDs will need to demonstrate NHS England’s support for the proposals and OBCs will need
to demonstrate that the proposals are sustainable for the in terms of rent re-imbursement.
9.2.3
Commercial and management implications
Commercial and management considerations will be explored at the OBC stage. These are
likely to include:





How services will be procured;
Which providers will provide services, and for how long;
What contractual mechanisms will be in place between commissioners and providers
(in an integrated model there may be several commissioners and providers from
across the public and private sectors);
What payment mechanisms are in place between commissioners and providers;
Detailed plans on how governance will work and the confidence that there is an
achievable plan and appropriate resources are in place for successful delivery.
Page 66
10 Next steps
This chapter describes the next steps for the development of out of hospital hubs, which will
begin with the development of a Project Initiation Document and Outline Business Case for
the priority site.
Figure 29: The Process to Develop the Out of Hospital Hub Model
Developing the OOH Model of Care
Out of Hospital
Out of Hospital Strategic
Project Initiation Document
Outline Business Case
Delivery Strategy
Service Delivery Plan
(Locality Hub specific)
(Locality Hub specific)
(WLCCG Wide)
(WLCCG Wide)
Setting out the locality Hub
Making the case for capital
Setting out the strategic
Quantifying the shift in OOH
requirements, the options to
investment and any increase
Content and approach to
care and understanding the
meet the need, the preferred
in rent reimbursement
OOH care in West London.
workforce and ICT implications
option, the proposed service
of the new model. Setting out
specification and financial
the space requirements and
implications
Full Business Case
(Locality Hub specific)
Setting out the detailed service
plan, financial arrangements,
management and
Implementation plan
potential Hub sites
Supporting Analysis
As demonstrated in the above diagram, this SSDP further develops the model and quantifies
the requirements, but does not conclude the process. There is now an evidence base to
support the need for additional Hub space to enable the wider model of out of hospital care to
be implemented in West London, but project initiation documents and business cases need
to be developed for each locality hub to persuade key stakeholders including NHS England
to support these proposals.
The next stages in the process will involve further analysis including activity modelling, space
estimation, financial modelling and transport accessibility assessments. This will underpin the
continuing development of the model of care, including service specifications and simplified
patient pathways that benefit the populations that we serve.
Page 67
11 Appendices
Appendix 1: List of West London estate as labelled in figure 2
Type
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Other NHS
Hospital
Hospital
Hospital
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
NHS Health
Centre
LA (Pipeline)
LA (Pipeline)
LA (Pipeline)
LA (Pipeline)
Other NHS
(Pipeline)
LA (Pipeline)
Potential Hub
Site - NHS
Potential Hub
Site - NHS
Label
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Name
133/134 KENSAL ROAD
306 KENSAL ROAD
ALISON HOUSE
ATHLONE NURSING HOME
BARNARD LODGE
ELMFIELD WAY
FLATS A, B AND C 291 HARROW ROAD
FLOREY LODGE
MILNE HOUSE
14 - 18 NEWTON ROAD
EMPERORS GATE HEALTH CENTRE
GERTRUDE STREET
KINGSBRIDGE ROAD LDU
PRINCESS LOUISE NURSING HOME
BARLBY ROAD CLINIC
EARLS COURT HEALTH AND WELLBEING CENTRE
St Mary's
Charring Cross Hospital
Chelsea & Westminster
20
ABINGDON HEALTH CENTRE
21
COLVILLE HEALTH CENTRE
22
KENSINGTON HIGH STREET 127
23
KENSINGTON PARK MEDICAL CENTRE
24
KNIGHTSBRIDGE MEDICAL CENTRE
25
ROSARY GADENS MEDICAL CENTRE
26
THE LIGHTHOUSE MEDICAL CENTRE
27
WALMER ROAD HEALTH CENTRE
28
KENSINGTON PARK MEDICAL CENTRE
29
SCARSDALE MEDICAL CENTRE
30
HALLFIELD CLINIC
31
HEALTH AT THE STOWE
32
33
34
35
CHELSEA TOWN HALL
THAMES BROOK NURSING HOME
WARWICK AVENUE
PEMBROKE ROAD DEVELOPMENT
36
WORLDS END HC
37
ROYAL BROMPTON
38
QUEENS PARK HEALTH CENTRE
39
VIOLET MELCHETT HEALTH CENTRE
Page 68
Potential Hub
Site - NHS
Potential Hub
Site - NHS
Potential Hub
Site - NHS
Potential Hub
Site - NHS
Potential Hub
Site - LA
(Pipeline)
40
WOODFIELD ROAD MEDICAL CENTRE
41
WORLDS END HEALTH CENTRE
42
ST CHARLES CENTRE FOR HEALTH AND WELLBEING
43
ST QUINTIN HEALTH CENTRE
44
EARLS COURT RE-DEVELOPMENT
Appendix 2: Draft service specification for West London hubs
Service Category
Associated Functions
GP Services (Core)
and enhanced (list
size)
 GP Appointments
 Nurse Appointments
 Minor Surgery (Levels 1&2)
Diagnostics
 Plain X-ray
 Ultrasound
 ECG
 Phlebotomy
 Echo
 Spirometry
Older Adults
 Older Adults team
 Older peoples assessment
 Falls
 Proactive Integrated Teams
 Reactive Integrated Teams
Patients with Term
Conditions
 Cardiology
 Respiratory
 Diabetes
Urgent care
 Urgent Care Centre
 7 Day GP access
Primary Care
Mental Health
Children’s Services
 Psychological Therapies
Sexual Health
Pharmacy
 Sexual health services
 Community Pharmacy
 CNWL Central Pharmacy
Community OP and
Treatment Services




End of Life Care
 Inpatient Beds
 Day care
 Education and Support
 Primary Care & Community
Staff Training and
development
 Staff hub for key
community staff
Other
 GP based Out reach
 Learning together
 Allergy and other diagnostic
clinics
MSK
Dermatology
Ophthalmology
Gynaecology




Diabetes
Health visiting
Immunisation
Sickle Cell
 Dental
 Podiatry
 Dietetics/Nutrition/SWM
Page 69
North locality examples
Community
Voluntary Services
 Open Age
 WAND
 Living Well
 Smartworks
 Gay Men’s Project
 The Women’s Trust
Public Meeting Space
South locality examples
 TBD
Page 70
Appendix 3: Out of hospital evaluation criteria
Three main stakeholder groups
have suggested a range of
principles for prioritising
investment in hubs and GP
premises:
 CCGs delivery strategies
and strategic service
delivery plans make clear
that providers will work
differently, and that
investment needs to drive
this improvement.
 NHSE has clear
expectations about the
affordability of business
cases and is prioritising its
limited funding carefully.
 NHSPS is focused on
ensuring space is utilised
effectively, and will only
support business cases that
deliver this.
Suggested principles

Alignment with OOH strategy: All OOH providers will adhere (i) to a
consistent set of OOH standards, agreed in CCGs’ OOH strategies and the
DMBC, and (ii) to delivery expectations from the CCGs’ OOH delivery
strategies and strategic services delivery plans.

Meeting local needs: Investment will meet the needs of as many local people
are possible, and help address variations in need and access. For hubs
(including premises hosting more than one practice), services will be located
to ensure sufficient geographic coverage and range of patients.

Affordability and value for money: Plans will offer good value for money and
be affordable to all stakeholders.

Commitment to space utilisation: Existing estate will be utilised as fully as
possible. All OOH delivery space (new or existing) will be configured as flexibly
as possible to ensure high utilisation.

Condition of estate: Estate used will meet relevant condition requirements
and be able to house an additional services.
In their application, the principles outlined above translate into three domains of criteria:
1
Threshold criteria
Reflect minimum standards for plans and business cases, covering estates, finance and scale requirements.
Enables CCGs to reduce the number of potential plans to a manageable number before prioritising.
Applied while developing SSDP and maintained throughout OBC development.
Principles
2
Prioritisation criteria
Multiple criteria offering CCGs a mechanism for prioritising competing plans and business cases, ensuring
funding is allocated in the most effective way to deliver out of hospital plans.
Applied while developing SSDP and OBCs.
3
Expectations of service providers
Clear expectations for any provider involved in the delivery of OOH services to ensure our standards are met
and care in delivered in line with CCG delivery strategies.
Defined during development of delivery strategies and SSDP, and then maintained throughout delivery.
The proposed criteria within each domain are based on the principles and would be applied
during the development process:
Page 71
1
Threshold
criteria
Proposed criteria
 Commitment to space utilisation: Plans for estate make
maximum use of spare capacity, and additional investment is
only considered when all spare space is used.
 Affordability and value for money: Plans are affordable, with
funding available from suitable sources.
minimum threshold, ensuring sufficient patient through-put.
 Condition of estate: Estate meets, or can be improved to
meet, minimum condition and access standards.
 Scope for expansion: Proposed estate can accommodate
new services.
2
Prioritisation
criteria
 Meeting local needs (hubs only): Catchment area meets
 Commitment to space utilisation: Plans with flexible estates
solutions are prioritised, including rooms that are multifunctional and can be re-purposed
 Condition of estate: Plans that improve the overall suitability
of the borough estate, by reducing the number of premises not
meeting requirements are prioritised
 Affordability and value for money: Plans are prioritised
based on their value for money
 Meeting local needs : Plans with more accessible premises
(e.g., proximity to public transport) are prioritised.
 Meeting local needs : Plans affecting larger populations are
prioritised
 Achieving our OOH strategy: Plans that make a larger
contribution to the delivery of the OOH strategy will be
prioritised.
3
Expectations of
service
providers
 Meeting local needs : Areas with higher levels of deprivation
are prioritised
 Commitment to space utilisation: Providers commit to full
space utilisation, including maintaining use of space and
sharing rooms where appropriate
 Alignment with OOH strategy: Providers commit to
integrated ways of working, including shared systems, network
working, integration with other services, and inter-referral.
 Alignment with OOH strategy: Providers commit to relevant
access / opening hours expectations, including
telephone/virtual access to consultations and extended
opening hours.
Criteria will be used to test proposals in this SSDP, and to evaluate options in the OBC
options appraisal for each proposed hub.
Page 72
Page 73
Appendix 4: Methodology for activity modelling
The total primary care activity estimation which will move into hub settings breaks down into
3 main sources of activity: baseline GP (core + enhanced), additional activity generated by
the ICP initiative, and additional activity generated by the shifting setting of mental health into
primary care.
In order to calculate the baseline primary care activity we applied an assumption on the
number of primary care appointments per patient (forecast out to 2018/19 levels). The
number of average appointments per person has been calculated by using the NHS average
attendances by age cohort (The Health and Social Care Information Centre, Trends in
Consultation Rates in General Practice 1995 to 2008: Analysis of the QResearch® database
and applying it to the age profile of Hounslow. Average for 2018 (core and enhanced) is 7.3
appts, 60% of the total appointments have been assumed to take place with GPs and the
remaining 40% with nurses (programme-wide assumption).
We have modelled the additional activity generated by ICP across 3 areas – care planning,
multi-disciplinary team meetings and additional regular primary care appointments – and
across 3 cohorts of patients (representing 0.5%, 4.5% and 15% of the total list size).
For care planning we have assumed that all 20% of the high risk patients will require a care
plan to be written, and that those plans will be completed over a 4 year span.
For MDTs it is assumed that 0.5% of the population requires 2 MDT reviews and 4.5%
requires 0.5 MDT reviews per year, with the allocation of MDT meetings to GP vs. Network
vs. Hub varying across CCGs, for Hounslow it is assumed that 100% of MDTs will take place
in hubs.
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Finally for additional regular primary care appointments we have assumed that the population
within the highest risk cohort (0.5%) will need an appointment per month, alternating between
GP, nurse and AHP, while population within the second risk cohort (4.5%) will need an
appointment quarterly. 50% of all GP and nurses appointments will be picked up by GP
practices. Within Heston these appointments are assumed to be 30 minutes in length (rather
than the normal average 12 minute primary care appointment).
ICP additional appointments
% of population requiring additional appts
0.5% 4.5%
15%
# additional GP appts per patient per annum
4
1
0
# additional nurse appts per patient per annum
4
1
0
# additional AHP appts per patient per annum
4
1
0
Total
12
3
0
Outpatient re-provision
The services to be moved out of Hospitals and into hubs vary significantly across the CCGs.
For WL the Outpatient re-provision target 2017/2018 was 59,000, 35% of the total Outpatient
activity in 2012/13.
7% reduction of Outpatient activity from referral management in the next five years was
assumed (Programme-wide assumption based on average of current QIPP RMS) and 100%
of the resulting re-provisioned Outpatient activity was assumed to move into Hub settings
(SaHF assumption).
Mental Health
For the shifting settings of care activity we have agreed programme-wide assumptions
developed with various MH CCG leads:

50% of Community Mental Health shifts to Primary Care (excluding CAMHS, Mother
& Baby community, Specialist teams and Memory services).
 20% of MH appointments will be picked up by GP practices. This number is added to
the primary care baseline activity.
For IAPT services we have used the NHSE national target that 15% of the total IAPT
demographic will be seen (Talking Therapies: A four-year plan of action), along with
programme-wide assumptions developed with various MH CCG leads:




The IAPT demographic is approximately 9% of the total list size.
Each person seen for IAPT will require 4 appointments on average.
50% of all IAPT appts will take place in hubs and 50% in networks.
All dementia appointments will take place in hubs.
Page 75
Minor Surgery
Two different methods have been used to estimate the total number of LES / DES
procedures that will shift to community settings, and the average of the two was taken:
The total number of day case procedures has been derived from SLAM (Service Level
Activity Monitoring) data. After consulting with each individual CCG, the percentage of day
cases that will shift to a PC setting has been identified. The total number of LES / DES
procedures and day cases has then been allocated to GPs, Networks and Hubs accordingly
using the following Programme-wide assumptions:
Allocation of Minor surgery
GP
Network
Hub
LES/DES
40%
0%
60%
Day cases
0%
0%
100%
Nursing and Reactive Intervention
A generic programme-wide assumption has been made that Nursing and Reactive
Intervention activity will take place in the community, and not in hubs. Reactive intervention
activity comprises: Intermediate care, Rapid response and Early discharge.
Specialist nursing staff will only undertake activity of administrative nature in hubs. For WL
we have made the assumption therefore that a group room per hub (ie.2 rooms) + an extra
room for St Mary’s will be needed to allow hot-desking/meeting space for those staff on the
occasions they are based from the hub for the day.
Additional CCG specific activity
A programme-wide assumption has been made that 50% of Rehabilitation, Physiotherapy
and AHP activity will move into a Hub setting while the remaining activity will stay within the
community. This assumption can be flexed depending on the individual CCG. Other
additional activity, specific to each CCG, such as Pharmacy, Teaching/Education and Dentist
activity has been taken into account following discussions with the individual CCGs and
space has been allocated as necessary. For WL we have assumed that six 50-people rooms
Page 76
will be needed to provide a training/ education room suitable for all staff and there will be
commercial space for two pharmacies.
Growth assumptions
In order to account for forecast demographic and non-demographic growth in activity over the
next 5 years we have taken assumptions from QIPP modelling and the latest MTMF plans to
estimate the yearly activity growth in the following categories:


Demographic (1.5% annually)
Non-demographic:
o Primary Care (3%)
o Mental Health (2%)
o Outpatients (3%)
o Community (Physiotherapy, AHP, Rehabilitation) (1%)
Page 77
Appendix 5: Methodology for translating activity into space estimation
Once the activity levels within the hub have been forecast we need to convert these figures
into an assessment of the amount of space which will be needed to deliver each service. This
is calculated in 3 steps: convert activity to a number of treatment rooms, convert treatment
rooms to net internal area (NIA) and finally convert net internal area into gross internal area
(GIA) which includes all corridors, heating/ventilation space etc.
Converting activity into numbers of treatment rooms
In order to calculate the number of rooms required for a given amount of activity we need 3
key sets of assumptions: the opening hours of the service, how much of the time within these
opening hours will be utilised for patient treatment and how long each appointment will be.
Combining the first two allows us to calculate the total annual patient facing time, and
dividing through by the average appointment length gives us a number of appointment slots
available per room per year.
Opening hours vary depending on the individual CCG’s service delivery plan (with the move
towards 7 day working in mind, but the utilisation of space for treatment within these opening
hours is based on programme wide assumptions agreed with NHSPS and with clinical input.
Similarly appointment lengths are standard assumptions with input from clinicians.
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Converting number of treatment rooms into NIA
In order to calculate this step we have applied standard ratios (calculated based on best
practice examples of other similar NHS estate) of the size of a treatment room to the
combined size of all of the support areas (utility areas, recovery rooms, waiting areas etc.)
needed.
The size of the treatment rooms were largely taken from the DH health building notes.
Page 79
And the ratios of treatment to support room space were based on analysis of the DH health
building note examples, as well as analysis of other buildings across NWL. The table below
summarises these (the ratio figures should be read as ‘for every 1m2 of treatment room
space, a further xm2 of support space is needed’).
Page 80
Converting NIA to GIA
Finally we take into account all of the other areas needed for a functional building including
circulation (corridors, stairs etc.), engineering and communications spaces. Again we were
guided by the DH health building notes, although at the request of NHS property services we
scaled down the total uplift slightly in accordance with their experience and in line with
analysis of other health buildings in the area.
Testing and validating our methodology
In order to ensure the accuracy of our methodology we applied it to a number of test cases
and checked against the actual building size.
Page 81
Appendix 6: Estates baseline for north and south locality property and rationale for exclusion from the process
North locality sites
List
Size
Property
Age
Space
utilisation
Tenure
W10 4LY AHMED N QUEENS PARK HEALTH CENTRE
2322
1976-1997
F
CLCH F/H
W10 6DZ BARLBY SURGERY
7371
Pre 1919
F
NHSPS F/H
W2 3QA
7825
Postcode
Name
BAYSWATER MEDICAL CENTRE
GIFA (m2)
842 (all 3
surgeries)
Reason for exclusion
Consolidated under QPMC
360
Below 500m
255
Below 500m
2
2
W11 1PA COLVILLE HEALTH CENTRE
3924
1976-1997
F
CLCH L/H
155
????
W10 6NX NORTH KENSINGTON MEDICAL CENTRE
4504
1976-1997
O
NHSPS F/H
200
Below 500m
W11 2SE WESTBOURNE GROVE MEDICAL CENTRE
7253
Pre 1919
F
Rented
232
Below 500m
W2 6HF
4571
1946-1975
F
PCT - leased
338
Below 500m
8663
Pre 1919
F
Owned
???
Below 500m (practice also relocating to town hall)
SHIRLAND ROAD MEDICAL CENTRE
3643
n/a
n/a
n/a
194
Below 500m
W10 5NY THE GOLBORNE MEDICAL CENTRE
4967
n/a
O
Rented
283
Below 500m
W10 5NT MEANWHILE GARDEN MEDICAL CENTRE
3025
n/a
F
Owned
386
Below 500m
W11 4LA PORTLAND ROAD PRACTICE
7508
1946-1975
F
Rented
348
Below 500m
W9 3QT
ELGIN CLINIC
4936
n/a
n/a
n/a
314
Below 500m
W11 1QT THE PRACTICE BEACON
1624
1976-1997
F
NHSPS L/H
143
Below 500m
W10 4LY NAGARAJAN QUEENS PARK HEALTH CENTRE
3235
1976-1997
F
CLCH F/H
842
Consolidated under QPMC
W11 3EP THE PEMBRIDGE VILLAS SURGERY
9872
Pre 1919
F
Part leased
277
Below 500m
W11 2EH THE NOTTING HILL MEDICAL CENTRE
3113
470
Below 500m
W2 1RU
MILNE HOUSE MEDICAL CENTRE
3147
Pre 1919
F
NHSPS Leased
206
Below 500m
W2 5EH
FLUXMAN HARROW ROAD HEALTH CENTRE
4368
n/a
n/a
n/a
945
W8 6PR
THE SURGERY
2283
F
Owned
74
Below 500m
W2 1NR
WEST TWO HEALTH CENTRE
3112
1976-1997
Owned
802
For sale/sold
W11 4ES THE FORELAND MEDICAL CENTRE
3943
n/a
n/a
159
Below 500m
W9 2AF
4972
Post 1997
Leased
213
Below 500m
THE GARWAY MEDICAL PRACTICE
W11 3SL HOLLAND PARK SURGERY
W9 3JJ
2
2
2
2
2
2
2
2
2
2
2
2
2
2
NEW ELGIN PRACTICE
F
Page 82
Below 500m and north hub space requirement - not
expandable
2
2
2
Postcode
Name
W11 4EG THE SURGERY
List
Size
Property
Age
Space
utilisation
Tenure
GIFA (m2)
Reason for exclusion
1711
n/a
F
Owned
150
Below 500m
2
2
W11 4NH THE SURGERY
2344
n/a
O
Owned
74
Below 500m
W10 6DZ EXMOOR SURGERY
3166
Pre 1919
F
NHSPS F/H
247
Below 500m
1410
1976-1997
F
CLCH F/H
842
Consolidated under QPMC
W10 4NJ SRIKRISHNAMURTHY HARROW ROAD SURGERY
2291
n/a
F
n/a
233
Below 500m
W11 2EH PORTOBELLO MEDICAL CENTRE
1744
n/a
F
Rented
470
Below 500m
n/a
n/a
n/a
Small list size suggests size below 500m
W10 4LY
W2 3ET
W2 5ES
LAI CHUNG FONG QUEENS PARK HEALTH
CENTRE
LANCASTER GATE MEDICAL CENTRE
2552
THE WESTBOURNE GREEN SURGERY
3948
W10 4RE HALF PENNY STEPS HEALTH CENTRE
4008
Post 1997
60%
PCT
97
Below 500m
2
2
2
2
2
Taken to prioritisation stage
2
W10 5GW 133/134 KENSAL ROAD
n/a
1976-1997
0%
NHS PS - LH
173
Below 500m
W10 5BE 306 KENSAL ROAD
n/a
1976-1997
60%
CLCH - LH
365
Below 500m
W9 3RN
FLATS A, B AND C 291 HARROW ROAD
n/a
1976-1997
60%
NHS PS - FH
621
Above 500m but cannot be expanded to meet space
requirement
W2 6HF
HALLFIELD CLINIC
n/a
1946-1975
40%
NHS PS - LH
327
Below 500m
W2 1RU
MILNE HOUSE
n/a
1976-1997
60%
CLCH - LH
205
Below 500m
2
2
2
2
W10 4LD QUEENS PARK HEALTH CENTRE
n/a
1976-1997
60%
CLCH - FH
787
Taken to prioritisation
W10 6AZ BARLBY ROAD CLINIC
n/a
1976-1997
E
NHS PS - LH
283
Below 500m
W11 1PA COLVILLE HEALTH CENTRE
n/a
1976-1997
F
CLCH - LH
1221
Above 500m but cannot be expanded to meet space
requirement
n/a
1946-1975
U
NHS PS - LH
299
Below 500m
W10 6PU KINGSBRIDGE ROAD LDU
n/a
1946-1975
F
NHS PS - FH
593
Above 500m but cannot be expanded to meet space
requirement
W10 6DL PRINCESS LOUISE NURSING HOME
n/a
Post 1997
F
NHS PS - FH
2577
Taken into prioritisation stage
n/a
Pre 1919
U
NHS PS - FH
19487
Taken to prioritisation stage
W10 6NX ST QUINTIN HEALTH CENTRE
n/a
1976-1997
U
NHS PS - FH
545
Taken to prioritisation – scope for expansion to meet
space requirement
W11 1QT THE LIGHTHOUSE MEDICAL CENTRE
n/a
1976-1997
F
NHS PS - LH
143
Below 500m
W11 4ET WALMER ROAD HEALTH CENTRE
n/a
1946-1975
F
NHS PS - LH
418
Below 500m
2
2
W8 5SF
KENSINGTON HIGH STREET 127
2
2
ST CHARLES CENTRE FOR HEALTH AND
W10 6DZ
WELLBEING
Page 83
2
2
South locality sites
Postcode
SW5 0EA
Name
Property Age
Branch of Brompton Rd surgery
(E87746)
Tenure
GIFA (m2)
Reason for exclusion
2
n/a
Rented
n/a
Small – less than 500m (anecdotal)
n/a
SW5 0EA
SW3 3JD
Brompton Road Medical Centre
Dr Rose’s Practice
Rented
Owned
n/a
Small list size (2341) suggests small practice
Pre 1919
205
Less than 500m
SW5 9AD
Earls Court Medical Centre
Pre 1919
Part Leased
581
Above 500m but property is old office in tube station.
Restricted in extension possible
SW10 9DT
SW7 5RB
The Redcliffe Surgery
Stanhope Mews Surgery
Pre 1919
Pre 1919
Owned
Rented
302
n/a
Below 500m
????
2
2
2
2
SW7 4HJ
Emperor’s Gate Centre for Health
n/a
NHSPS Leased
810
Above 500m but cannot be expanded to meet space
requirement. In a converted church in a residential
property
SW7 4NQ
Rosary Garden Surgery
n/a
HA Leased
n/a
Small list size (2341) suggests small practice
(anecdotal suggests small building)
SW5 9JZ
SW10 0UD
The Surgery
Kings Road Medical Centre
n/a
n/a
Small list size – likely to be small GIFA (<500m )
1946-1975
n/a
n/a
121
Below 500m
SW7 2SU
SW3 5RR
The Surgery
The Chelsea Practice
n/a
1920-1945
Owned
NHSPS Leased
2
2
Small list size (2331) suggests small practice
133
Below 500m
2
2
W8 6EG
The Abingdon Health Centre
n/a
NHSPS Leased
643
SW7 4QS
The Surgery
n/a
Owned
n/a
SW3 4SR
Royal Hospital Chelsea
W8 5SX
SW3 6PX
Scarsdale Medical Centre
The Surgery
Pre 1919
Above 500m but cannot be expanded to meet space
requirement as it is a terrace in a parade which will
have to be expanded to 3x current size to meet space
requirement
Residential property, small. Small list size (1468)also
suggests small practice
138
Below 500m
2
2
1976-1997
NHSPS Leased
243
Below 500m
n/a
Owned
n/a
Residential property, small. Relatively small list size
(3196) suggests small property (less than 500m”)
Page 84
Postcode
Name
Property Age
Tenure
GIFA (m2)
Reason for exclusion
W14 8HW
Kensington Park Medical Centre
1976-1997
NHSPS Leased
550
Above 500m2 but cannot be expanded to meet space
requirement. Ground floor practice in a residential
property. Unlikely to be able to expand to meet space
requirement
SW1X 0ET
Knightsbridge Medical Centre
1920-1945
NHSPS Leased
426
Less than 500m2
The Surgery
n/a
n/a
n/a
Old converted house. Small list size(1663) suggest
small practice
SW10 0LR
The Good Practice
n/a
Rented
n/a
Relatively small list size (3344) suggest small practice.
No spare capacity
SW5 0PT
Earls Court Health and Wellbeing
Centre
1920 - 1945
NHS PS - LH
728
Above 500m2 but cannot be expanded to meet space
requirement. Ground floor practice in a residential
property. Unlikely to be able to expand to meet space
requirement
SW10 0JN
Gertrude Street
1946-1975
CLCH - LH
173
Less than 500m2
SW5 9JA
SW1X 0ET
Knightsbridge Medical Centre
SW7 4NQ
Rosary Gardens Medical Centre
W8 5SX
Scarsdale Medical Centre
SW3 5RR
Violet Melchett Health Centre
SW10 0UD
Worlds End Health Centre
1976-1997
NHS PS - LH
501
Above 500m2 but cannot be expanded to meet space
requirement. Ground floor practice in a residential
property. Unlikely to be able to expand to meet space
requirement (will have to expand to 3 times current
size)
n/a
NHS PS - LH
170
Less than 500m2
1976-1997
NHS PS - LH
317
Less than 500m2
CLCH - LH
1848
Potential to meet space requirement if commissioning
adjustments are made. Taken to prioritisation stage
CLCH - FH
1073
Potential to push estate to meet space requirement if
expanded into car park
1976-1997
Page 85
SW10 9EL
Chelsea Chambers
n/a
CNWL
510*
Building is spread over four floors but has no lift
facilities currently, which severely restricts use of the
upper floors. The lease has 8 years to run so it may be
possible to install a lift (subject to site survey) although
this would need significant investment and landlord
approval. Also looking at the floor plans and wall
thicknesses shown on the drawings it looks like any
adaptation to suit specific need might be limited.
Pipeline estates
Status of pipeline estates in the south locality
Estate
Approximate time to
completion
Status
Planning application approved. Notified that there may be more residential
units than initially thought, creating space for some space or revenue
Warwick Avenue
contribution. Follow up to understand the nature of changes and implications
for the CCG
Potential regeneration underway with a potential for space to become
Royal Brompton Hospital
available.
Thamesbrook Nursing
Development of this estate is at least 5 years away (same timeline as Earls
Home
Court)
Development of this estate is at least 5 years away.
Earl Court Redevelopment
Guaranteed size as part of s106 agreement
Pembroke Road
Re-development programme is about 10+ years away
Redevelopment
New Marlborough School
2
Approximately 3000m of space will be available through this LA development
(SW3 3AP)
Page 86
> 3 years
> 3 years
≥ 5 years
≥ 5 years
≥ 10 years
2016
Sources of Estates
The data has been collected from a number of sources, to populate the estates baseline across GP, NHS and Local Authority estates:






GP estate information (6-facet, property age, tenure, GIFA, use of premises) is sourced from Drivers Jonas Deloitte (DJD) between 2007 and 2013.
GP DDA rating and capacity analysis was completed by DJD in 2012/3 (brief surveys from September 2012 – January 2013) for a third of GP
surgeries in West London. Note that where this information is available, this is more recent and accurate than the 6-facet condition rating
Where 6-facet data are not available or are deemed to be out of date (some of data were from 2007), NHS PS has advised Premises Sub-group as
to a qualitative assessment of capacity and condition;
Data on health centres and pipeline buildings has been generated through meetings with NHS PS
Local Authority (LA) information has been collated from meetings with both the LAs and NHS PS, who have advised on Section 106 opportunities,
disposal LA sites and development opportunity within the CCGs;
Data has been reviewed by NHS PS and where available the CCGs to validate information obtained.
Page 87
Appendix 7: Prioritisation Exercise for Shortlisted Estates
1. Achieving our OOH Strategy
●
●
This criterion scores hubs/sites as to whether they are able to deliver West London’s
Out-of-Hospital Delivery Strategy
All hubs should score positively on this criterion
2. Value for money – high level cost if site
●
●
High level capital cost to be attached to project based on whether it is a light, medium
or heavy refurbishment or a new build. Costs estimates supplied by NHS Property
Services and Turner & Townsend*. Not adjusted for optimism bias.
The following space requirement have been assumed based on the activity modelling:
● 1200m² GP space and 1,200m² other OOH (north)
● 900m² GP space and 900m² other OOH (south)
Scoring notes
2
2
* New build construction costs estimates £2,500-£2,700m (NHSPS) and £2,600-£2,900.m
(Turner and Townsend)
** Violet Melchett is currently fully utilised and as such services will need to be recommissioned to create space for hub services (not possible to co-locate full hub space with
existing services)
Page 88
*** World’s End can be expanded to provide the additional space required for the hub
services. Scope for additional space means it is possible to co-locate hub alongside existing
services being provided
**** Size of new build reflects the fact that extra space will be needed to accommodate
2
services that will be taken out of VM to accommodate the hub (it is expected that 800m of
2
GP space is needed and 875m for OOH activities assuming 50% of current OOH needs to
be moved out)
3. Accessibility
 The public transport accessibility level (PTAL) is a method used in UK transport
planning to assess the access level of geographical areas to public transport
 PTAL is a simple, easily calculated approach that hinges on the distance from any
point to the nearest public transport stop, and service frequency at those stops
(bus, underground and rail)
 Population density will also have a significant impact on accessibility, so these two
factors should be considered together
 A PTAL score of 1a indicates extremely poor access to the location by public
transport, and a PTAL of 6b indicates excellent access by public transport
 The DDA rating of the estate will also be assessed using outputs from the Estates
Baseline Survey
Page 89
Scoring notes
* Distance from VM to tube (Sloane Sq.) is 14 mins by foot and 10 mins (by bus). Distance
from WE to tube (Fulham Broadway) is 13 mins walk and 8 mins by tube. Based on the PTAL
scoring algorithm, WE has a higher PTAL score than VM as VM is just outside the 12 mins
time boundary. However, in this exercise, we have adjusted for VM so that it matches WE as
both places are similarly accessible
** Based on Niddry Lodge brochure which says building is ‘DDA compliant
4. Commitment to space utilisation


Judgement from NHSPS as to the potential future flexible use of the site once developed.
Both sites would be developed with this in mind so both score positively.
Commitment to NHS estate utilisation favours existing sites/land owned or leased by the
NHS
Scoring note
* The lease for Violet Melchett expires in~2017 with no guarantee of being able to renew the
lease, making it less flexible than other options. The lease has an in perpetuity element to the
lease which creates opportunities for s106 re-provision.
Page 90
5. Condition of estate
This suitability of an option is scored based on the number of poor quality GP premises (C or
below) are within 0.5 miles of the hub and which could move into the potential hub. Assume
that it is preferred to not move B premises into a hub so that will score negatively.
Scoring notes
* Shirland Surgery/Srikrishnamurthy Surgery
** 2 Surgeries in St Quintin’s Health Centre, Practice Beacon, © - Golborne
*** Exmoor Surgery and the Practice Beacon
**** “Cs – Dr Rose’s Surgery, Royal Hospital Chelsea, 1B – The Surgery
***** 2Bs – Redcliffe Practice and The Good Practice
****** 3Cs – Scarsdale Surgery, The Surgery, Abingdon Health
******* 2Bs – The Surgery, The Surgery, 3Cs – Royal Hospital Chelsea, The Surgery,
Chelsea Practice, Dr Rose’s Practice
6. Population
Population density from 2011 census was used, with more densely populated areas scored
highly. Also considered is the percentage of the population that are over 65 in the locality
with a high percentage of older population scored highly. West London-specific quintiles were
used, with sites being scored on the basis of the predominant local quintile colour.
Page 91
Population density (total population) data for West London CCG
Source: 2011 Census data
Page 92
Population density (over 65s) data for West London CCG
7. Deprivation
Index of deprivation from 2011 census was used, with more deprived areas scored highly.
West London-specific quintiles were used, with sites being scored on the basis of the
predominant local quintile colour.
Page 93
Deprivation data for West London CCG
Page 94
Appendix 8: Section 106 opportunities in West London
Location
Description
Imperial West
H&F/Westway
Primary care facility
identified circa
1000m2
Primary care facility
identified circa
1000m2
Edenham
Way/Trellick
Tower
Primary care facility
identified no size
confirmed
Earls Court
Old Oak
Elkestone Road
4 Phase
development circa
3255m2 total
Multi-storey
development
including Primary
care provision
Capital
Value
NK
Revenue
impact/(cost
pressure)
NK
NK
NK
NK
NK
£8,805,000
NK
NK
Anticipated
Funding
Capital
Fit with CCG Vision
Short/Medium/Long
term
Likelihood of
Delivery
£744,000 Sec
106
Yes- improved access
to primary care
Long
Med-S106 in place
£500,000 Sec
106
TBC
(social
infrastructure
grant)
TBC
(social
infrastructure
grant)
Yes- improved access
to primary care
Long
S106 in place
Relocation of premises
Long
RBKC led-
Yes- improved access
to primary care
Long
Potential S106
Brompton
Hospital
SPD stage only
NK
NK
Potential S106
Notting Hill
SPD stage only
NK
NK
Potential S107
Provision of improved
premises and potential
for enhanced list sizes
Provision of improved
premises and potential
for enhanced list sizes/
OOH delivery
Provision of improved
premises and potential
for enhanced list sizes
Page 95
Medium
Medium/Long
Medium/Long
High- Developer
pushing for CCG
response/requirement
Medium-planning
process only just
commenced
Medium-planning
process only just
commenced