Governing Body report
Paper: 5.1
Date
20 January 2015
Title of paper
Out of Hospital Programme Update
Presenter
Yvonne Fraser, Practice Manager representative and Lead for Putting Patients First
Author
Jayne Liddle
Responsible Director
Jayne Liddle
Clinical Lead
Fiona Butler
Confidential
Yes
so)
No
(items are only confidential if it is in the public interest for them to be
The Governing body is asked to:
- Note the lead health provider selected for the Community Independence Service (CIS)
- Note the launch of an Older Adults Support Team
- Note the update on Delayed Transfer of Care and Chelsea and Westminster Position
- Note update on the Operating Plan targets
- Note update on Whole Systems Integrated Care- Long term mental health needs
- Note update on GP Federation and Co Commissioning
- Note update on identification of South Hub
Summary of purpose and scope of report
1. Community Independence Service (CIS)
The CIS Lead Health Provider selection process has now concluded and Imperial College Healthcare NHS Trust (ICHT)
and partners are the single recommended bidder for this role.
ICHT led a consortium made up of a wide range of existing providers and GP providers in Tri-borough along with a
variety of partners in healthcare.
The CIS Lead Health Provider will work in partnership with the CIS Lead Social Care Provider to deliver the service in
the transitional year of 2015/16. Over the next three months, commissioners will work closely with providers and
stakeholders to ensure operational readiness for ‘go live’ on 1 April 2015.
2. Older Adult’s Support Team (OAST)

The OAST was launched on 15 December 2015

The service currently runs out of Chelsea & Westminster Hospital and offers a clinician to clinician telephone
triage service with three outcomes; Domiciliary Visit, invitation to OAST clinic or telephone advice.

Clinicians are also available to attend practice multi-disciplinary teams
Page 1 of 7
Governing Body report
Paper: 5.1

Currently there is on average one referral per day since the service launched – 50% of appropriate referrals
resulted in a domiciliary visit and they are thought to have prevented an admission.

In the North of the CCG, the same service is currently running out of St Mary’s Hospital. A steering group is
currently being set up with Imperial College Healthcare NHS Trust to ensure the same pathways are used.

Communication plan has been implemented and promotional flyers have been produced, which are
currently being distributed to practices.
3. Delayed Transfers of Care (DTOC)

West London CCG is currently supporting Chelsea & Westminster with their DTOCs

Reports are received biweekly and a meeting with the joint commissioning team is currently being arranged
to ensure an appropriate pathway is in place for commissioner intervention.

Before Christmas there was an average of 10 patients who were considered DTOCS – majority awaiting
continuing healthcare assessments or neuro-rehab beds.

Since Christmas this number has been below five.
4. Operating Plan Targets
Care plans (50% of over 75s to have a care plan by March 2015)

On track to achieve operating plan target.

295 care plans are needed to reach the operating plan target.
Primary Care Mental Health Service (PCMHS) referrals (15% of patients with depression / anxiety to enter
psychological therapies)

Q4 will see an increase in activity for the PCMHS, responsible for delivering the Access and recovery targets,
which are 15% and 50% respectively

A robust communications plan has been initiated with a public facing rebrand of the PCMHS to ‘Take Time to
Talk’, this includes a website, promotional materials and leaflets about what is offered via the service. To
achieve the target, 443 patients per month (or 1,329 for the quarter) are required to enable delivery of the
15% access. This will require a significant uplift in referral rates as there is a 33-40% attrition rate. The
service has regularly attended Commissioning Learning Sets meetings to promote the service, has been
developing plans about reducing wait times and also developed core targets around long term conditions,
black, minority, ethnic and refugee residents, Older Adults and opt-in for patients. The service has
established a hub at St Charles which recently expanded.

The recovery rate is still lower than anticipated, under 40%, but the strategy will be to increase appropriate
referrals e.g. depression and anxiety for 1 in 4 people. Data currently includes primary care liaison nurse and
Step 4 Psychology. The patients in this cohort take longer to recover and this is a significant factor in the
lower than anticipated recovery rate.
Page 2 of 7
Governing Body report
Paper: 5.1
Dementia ( 67% of patients with dementia to have been diagnosed)

At December 2014 the CCG reached 1079 of the 1147 dementia patients required for the quality outcomes
framework (QoF) register. This means that that CCG has achieved 63.3%, and a further 68 patients are
required to reach the target. A recovery plan has been developed between the management and clinical
leads to ensure that the CCG achieves this ambition. In January 2015 the clinical leads will be undertaking
visits to a number of high prevalence practices who have very low QoF register rates.

Additional capacity to help achieve the target has been commissioned.

A small team of two nurses and an occupational therapist has been recruited across West London, Central
London and Hammersmith & Fulham CCGs to further support the achievement of the target, build
confidence and support practices.

The CCG has communicated with practices regarding the designated enhanced services (DES) requirements
and the NHSE coding exercise in December and January
5. Whole Systems Integrated Care (WSIC) – Long term mental health needs(LTMHN)

The first of four co-production events commenced on 7th January 2015, and build upon work to date
including previous co production events in May 2014. A group of 22 stakeholders including, commissioners,
voluntary sector, CNWL, Service Users and carers have been selected to attend all four sessions.

Further to this, there has been significant engagement with through Local Network Delivery Group meetings,
engagement with local GP practices and CLS meetings. The two clinical leads, Dr Jiwani and Dr Squiers offer
capacity to our mental health Clinical Lead and are now embedded in the development of the model and
engaging their peers.

As part of the development of the WSIC LTMHN Model of Care we have identified key principles which still
need refining and the emerging model of care may be subject to change depending upon the co-production
events. CLS visits in October have resulted in wider engagement with our members and they had an
opportunity to feed in questions and ideas about how and what a developing model of care should include.

An outline Business Case is to be developed and the project manager working across the two early pioneer
sites in West London and Hounslow CCGs will be responsible for pulling this together with support from the
CCG mental health team.
6. Primary Care
Federation Development

A number of legal options for the emerging Federation and their implications have been explored by a group
of Steering Committee members, with targeted legal support.

Acknowledging the structures currently in place, the preferred option for the new Federation is to develop
the existing LMA into a larger body that all practices (PMS, GMS and APMS) can join. This ‘reconstituted’
LMA is likely to require more directors and a re-elected board, to be consistent with the requirements
outlined above. Additional arrangements to ensure that it meets the needs of new and existing members
are yet to be defined.

Our next steps are to focus on three clear workstreams (Legal/ Governance, Finance, and Process/
Capability). An all practice engagement meeting was held on 13 January 2015, to ensure member practices
were aware of progress and next steps. This included information on PMcF proposals for their agreement,
Page 3 of 7
Governing Body report
Paper: 5.1
before submission to Investment Committee.
Co-commissioning

A proforma expressing interest for delegation was submitted to NHS England on 9 January 2015; submission
has been made with the proviso to reserve the right to revert to joint co-commissioning depending on
outcomes of further CCG membership consultation.

The CCG is now entering into a shadow period in which we will explore further the potential of cocommissioning. During this shadow period all decisions will continue to be ratified by CCG Governing Bodies
and NHS England. NHS England launched guidance for Co-commissioning and for conflict of interest
management. CCGs will be further exploring delegation as a way forward. Work is progressing, together
with London Local Medical Committees.
7. Planned Care
Community diagnostics services procurement

The procurement of diagnostic services to replace the existing contract is now in the mobilisation stage. A
recommendation that a contract be awarded followed assurances on service locations. Bidders were
informed of the outcome of the procurement on 18 November 2014. The terms of the contract are now
being negotiated with the new provider in advance of service commencement for 1 April 2015.
Community dermatology service

Long waiting times continue to be a challenge for the community dermatology service.

Chelsea and Westminster is actively seeking further consultant capacity from either agency or private
sector. In addition, further capacity will become available as the services’ SpRs increase the proportion of
time they are able to spend with patients following their training (from 50% currently).

As set out in the CCG’s 2015/16 contracting intentions, the procurement of a new community dermatology
service for 2015/16 is being progressed jointly with Central London CCG. The draft specification for the
service was discussed at the Out of Hospital Committee in November. A bidders event was held on the 3
December 2014 to discuss the service with potential providers and the pre-qualification questionnaire and
invitation to tender were published before Christmas. Bids will be submitted by 30 January 2015.
Community Cardiology and Respiratory services

The existing community cardiology service provided by Imperial College Healthcare is expanding, with the
provision of services at St Charles Centre for Health and Wellbeing. This has been discussed at CLS events to
raise awareness of the expanded service which will include GP Direct Access Tests (ECGs, Echos, 24hr ECG,
24hr BP), Chest Pain Clinic, Breath Assessment, and Cardiology Outpatients. The service is now accepting
referrals and started seeing patients on Monday 15 December.
MSK

The Out of Hospital Committee endorsed the clinical model 14 October 2014. A business case for the
development of the current community MSK service to include an integrated rheumatology service was
Page 4 of 7
Governing Body report
Paper: 5.1
approved by the Finance & Performance Committee in November and has now been implemented. As part
of the work of the Outpatient Care Programme Board the CCG is working with Chelsea and Westminster to
introduce the routine triage of MSK referrals to ensure that the community service is being utilised
fully. This will commence in January 2015
8. Resilience Planning
Intermediate Care beds

Step up/down wards were launched in November at Chelsea & Westminster Hospital and Central London
Community Healthcare. The Inner North West London Urgent Care Board (UCB) is monitoring progress of
these schemes and they are being utilised to step patients down from acute beds. The UCB gave a steer that
capacity should be used for step down rather than step up from primary care, given the pressures on the
acute trusts at present.
London Central & West Unscheduled Care Collaborative (LCW) pilot

Funding has been agreed for LCW to provide a GP in the 111 call centre, to assess complex calls with the aim
of reducing unnecessary 999 and ED dispositions
9. Ellesmere interim re-provision

At present the CCG has 10 rehabilitation beds commissioned by Royal Borough Kensington & Chelsea; these
beds need to be re-provided by the end of January. All 10 beds are currently empty.

Five beds to be re-provided by Chelsea & Westminster in their Ransford Mowlem resilience intermediate
care ward, unfortunately this cannot be increased further.

Discussions with Imperial College Healthcare about the possibility of increasing capacity on their Marjorie
Warren resilience intermediate care ward are underway.

Funding for these new beds will be cost neutral.
10. Network Learning Forums
Monthly North/ South Network Learning Forums

Meetings attendance has increased with an average attendance of 25 people per meeting, with consistent
representation from GP, nursing, social care, case managers, pharmacists and primary care navigators.

The themes covered in the last quarter were asthma & COPD, MSK and Paediatrics

90-100% of people strongly agreed or agreed that the meeting was a good learning experience

50-90% of people said they thought what they had learnt would prevent a non-elective admission.
Network Learning Forum Plus

December saw the Launch of a series of two events that covered issues that arose from the monthly
Network Learning Forums. The Safeguarding event was held on 19 December 2014
Page 5 of 7
Governing Body report
Paper: 5.1

Attended by representatives from 18 practices (in the main, GPs attended)

Anecdotal feedback reported a well-received event (formal feedback being sought January 2015)
11. Out of Hospital Estates
Establishment of OAST and Whole Systems at St Charles

The business case for the refurbishment of an area of the ground floor at St Charles to provide, clinical, office
and meeting room space for the OAST team, CIS and voluntary sector partners has been approved by the
CCG Finance and Performance Committee. The refurbishment works are to be funded by the CCG on the
same basis as the accommodation for Community Cardiology and Diabetes (ie the expenditure has been
confirmed as revenue by nature).

Although the development is funded by the CCG it will require support from NHS Property Services (PS)
Asset Investment Group and a submission has been prepared for the January meeting. The outline
programme indicates that if NHS PS approval is gained by the end of January, works should be complete and
the area operational by spring 2015.

The business case also included costs for the appointment of a Service Development Manager to oversee the
works and establishment of the service. A key role for this postholder will be linked with the development of
the integrated working model at St Charles.
St Charles Integration Charter

The stakeholder event held on 18 December 2014 was a very well attended by service providers at St Charles
and key community partners. The session identified the specific benefits to patients, services and the
community of integrated working at St Charles. The workshop proceeded to define the key elements of a
charter, to which all providers will operate, and service specific commitments to implement the model.
South Hub options workshop

The engagement of the GPs within the south in the selection of the location for the South Hub began in
earnest with a workshop for all practices on 8 January 2015.

15 of the 22 practices were represented and contributed to a helpful and constructive debate on the shape
of the hub in the south and the services to be delivered, including the basis for the GP list size envisaged to
ensure a Primary Care Lead operating model. The attendees also debated the criteria they believe should be
applied to appraise the options available.

Six options were outlined although a priority assessment was not undertaken at the workshop. Further
discussions will be co-ordinated through extended CLS meetings during January, February and March. The
importance of linking this with the Federation development and Whole Systems Co-design Group to provide
project governance and structure was also agreed.
Quality & Safety/ Patient Engagement/ Impact on patient services:
-
The entire Out of Hospital agenda is to develop services closer to patients’ homes and our key
transformational programme have patients involved in design.
Page 6 of 7
Governing Body report
Paper: 5.1
-
Regular updates on Transformation Schemes are provided to the Patient Reference Group
-
Co design events are planned for both Whole Systems Early Adopter Schemes
Financial and resource implications
St Charles Business Case agreed at Finance and Performance Committee, 30 December 2014.
Ellsemere nursing home re-provision costs are cost neutral
Equality / Human Rights / Privacy impact analysis
Equality Impact Assessments will be completed as business cases are developed for new initiatives including the
South Hub
Risk
There is a risk that investment resources for 2014/15 are not spent within year.
Supporting documents
None
Governance and reporting (list committees, groups, or other bodies that have discussed the paper)
Committee name
Date discussed
Name
DD/MM/YYYY
Outcome
Page 7 of 7