Thanks to leaders and staff across the system for your hard work in another challenging winter for health and care services. Our weekly Gold meetings continue to help with coordinating the work across different teams. We have seen good progress on hospital discharge this week, but work continues across the system to improve it, including dedicated borough plans. We are also seeing increased occupancy in virtual wards and more 111 calls answered within 60 seconds – abandoned calls are down to 3.8% against a 5% national target.

Take-up of flu and Covid vaccinations has been a challenge across London. While there has been a small improvement in the last few days and we are performing better than other London systems in this area,, we are not where we would like to be with vaccination. Our winter communications plan will see an increase in both social media activity and direct engagement with communities where uptake is lowest making in the next couple of weeks.  Specific work is also planned to run dedicated clinics for children’s vaccinations, which is the area of lowest uptake.

A programme of organisational design continues in the ICB, following the national decision to reduce ICB running costs and an identified need to ensure we have the right capacity, capability and culture to deliver our statutory responsibilities within the ICS.

The programme has five linked projects, looking at overall organisational design (structure), HR processes, workforce development, running cost efficiency and organisational effectiveness, looking at our systems and ways of working. We are looking to make efficiencies in estates as well as people and processes, with a proposal to reduce the number of ICB office sites.

During the engagement phase this month, we will be talking to staff and partners about our initial ideas. Consultation with affected staff will then follow in the new year.

The population health management and health equity academy is now live on the ICS website. There is an offer against all five population health management skills domains (Analytics, Engagement, Leadership and Facilitation, Co-production and Health Economics/Value-based care), as well as a section on aligned resources and training opportunities aimed at supporting the development of wider skills and knowledge. The current offer will be further developed over the coming weeks. We are planning delivery of training on co-production and health economics/value-based care and will work with providers to make sure this is tailored to be as practical, meaningful and impactful as possible. Training will be available early in the new year.

Following on from last month’s successful health and wellbeing event to improve black health outcomes, the team is planning further events in collaboration with Hammersmith & Fulham, Kensington & Chelsea and Westminster. Over 300 people attended the last event, particularly from our more deprived areas, and the health checks identified people with hypertension, those at risk of diabetes and a significant number were seen by the mental health team. In addition, the themes coming out of last month’s health equity summit are shaping the activity of the health equity programme and a full summary and the presentations from the day can be found here.

The refreshed NW London ICS Anchor Charter has been developed with community leaders, anchor leads and endorsed by executive leads across the ICS and the charter will be launched at the ICP meeting on 7 December. The NW London anchor pledges focus on commitments to ensure we maximise employment, embed social value into contracts and use our assets to benefit our communities and address the wider determinants of health. On the 13 November we launched the anchor community of practice where anchor leads came together to share best practice and learn from each other and maximise opportunities that could benefit our communities.

On the 17 November the Health Equity Programme Board approved our strategic approach to developing a more joined-up approach to prevention. Over the next six months we will be looking at how we can work more collaboratively across all our system partners to create coherency around our existing prevention work and identify opportunities to further support our population to live healthy lives. Work has already started to ensure we have a joined up and comprehensive response to support tobacco dependency and control across the system. The new pathways will provide a consistent approach to ensuring that all people in contact with these services are offered the opportunity to quit smoking.  

Public consultation on the future shape of acute mental health services in Westminster and Kensington and Chelsea continues, running for an extended 14-week period up to the end of January. The ICB, CNWL and the two local authorities are working together to get the word out about the consultation and encourage local people to respond. Local events are taking place with more to follow. You can keep up to date with the consultation on our website.

As we have confirmed previously, no changes to mental health beds will be made until our overall mental health strategy for North West London is agreed. Public engagement on this strategy has continued to take place over the last couple of weeks. 

The statutory team enabling pathways (STEP) project in Westminster is an enhanced service for rough sleepers with mental health needs. The service launched in April 2023 and early evidence shows a reduction in attendances at A&E, improving users’ engagement with substance misuse services and is receiving positive feedback from service users and referrers. 

The NHS 111 first for mental health service went live in NW London on 14 November 2023. This is now successfully managing calls from residents in mental health crisis via NHS 111 (Mondays to Thursdays, 12 - 8pm). There are plans to ramp up to 24/7/365 by April 2024. NW London was the first ICB in London to go live with this service. 

Two centralised Section 136 (s136) hubs are now operational in London. These hubs offer a bespoke telephony service that allows Metropolitan Police officers to consult directly with a senior mental health practitioner, so that patients can be quickly referred into the most appropriate place of care or service. This is expected to reduce the number of attendances at emergency departments and reduce the use of s136.

Work has continued on the refresh of the children & young people’s (CYP) mental health transformation plan for 2024/25. Draft milestones include: 

• ensuring that there is effective representation and input from young champions at future CYP mental health steering groups
• continued delivery of the ‘Thrive’ framework with an additional focus on mental health support teams, including the rollout of six additional teams
• enhanced delivery of community crisis mental health provision
• enhanced support for neurodiverse CYP
• more effective mental health support for looked-after children.
• The full draft refresh will be available in January 2024.

As part of the ambition to reduce waiting times and waiting lists for autism and ADHD assessments, a programme of work is underway to develop an integrated neuro-developmental pathway for children and young people. To date, this includes a data collection exercise to inform priority-setting, and an exercise to map existing pre-and post-diagnostic support provision. It is intended that enhanced support for neurodiverse CYP will be launched in 2024/25.

Borough level discharge recovery plans have been signed off, setting out how boroughs and the ICB collectively will make improvements on our discharge position for winter. The NW London discharge framework has also been agreed which is a step towards a more standardised process. This will help system partners have a shared understanding of responsibilities around discharge, clearer processes and clarity on areas like patient choice and escalation.

North West London residents are currently being asked to provide feedback on potential service options for delivery of the new model of care for adult (18+) community-based specialist palliative care. The proposed new model of care has been co-designed over the last year by a working group of NW London residents, along with clinicians, NHS providers and charitable hospices with the ultimate goal of making sure there is improved access to high quality services. Details of the potential service delivery options have been published and a number of webinars are being held at both a borough and NW London level. People also have the opportunity to input via a very simple survey and direct by email. Further information can be found here.  

A funding request for WSIC dashboard development was successful, which will support some key priority areas for our long-term conditions programme. 

The Know Diabetes service and diabetes team have been celebrating world diabetes day, as part of this they have been doing out-reach to support the uptake and use of the Know Diabetes online platforms.

We have made good progress on standardising an approach to manage patient transport with all requests now going to nhsnwl.neptsapprovals@nhs.net

Colleagues in the respiratory clinical reference group did really well at the HSJ awards being highly commended for the asthma dashboard.

The terms of reference for the Better Care Fund review have been agreed, which is a key building block to our shared review of the services that are commissioned via the Better Care Fund. 

Over the last month the ICS has run some very well attended GP webinars, delivered by consultants from our clinical reference groups, covering the management of patients with liver disease and the management of patients suffering from dizziness.

The ICB and acute trusts have successfully implemented the ‘patient initiated digital mutual aid system’ (PIDMAS). This is part of the national alternative choice programme, which involved contacting over 15,000 long waiting patients in the sector to offer the opportunity to submit a request for earlier treatment at a different hospital.  Uptake has been similar to the national average and the ICB has successfully identified alternative capacity for over a third of requests processed to date.

Following the publication of the women’s health strategy, we have launched a questionnaire to find out about women’s experiences of healthcare. This will help shape our NW London strategy and plans for women’s health”.

The lung health check pilot has now been expanded. The pilot has been running in both NW and SW London since 2022 (approved by NHSE to become the fourth cancer screening programme). RM Partners, the Cancer Alliance for NW and SW London has been tasked with expanding the reach of the targeted lung health check (TLHC) service to cover the whole alliance population by 2027. 

Following a competitive tender process, the new service provider partner, In-Health, has begun to deliver the expansion of the service. 

Those who are at a higher risk of developing lung cancer (those with a smoking history), will be invited first as the service expands across all boroughs in 2024/25. 

Invites will be sent in December for Ealing residents to attend for a health check and if indicated, a low dose CT scan in January. Partner organisations across the ICB have been supporting this work, including GP practices, communications teams and Imperial College Hospital colleagues to ensure that this screening programme is a success. In West London TLHC is picking up stage 1 and 2 lung cancers at about 80%, this is compared to ~32% through other routes, such as two week wait referral or emergency presentation at A&E.

NW London’s revised overarching estates strategy and proposed high-level delivery plan was endorsed at the ICB’s strategic commissioning committee (SCC) this month. The newly formed estates programme board, chaired by SRO Steve Bloomer (CFO) met on 22 November to confirm next steps and commence implementation.

The strategy commits to:

•  developing and improving hub plans to support the transformation and delivery of services, aligned to changing population demographics and demand projections
• improving the integration of services, fitness-for-purpose and utilisation of our existing estate
• reducing void and unused bookable space costs to the ICB (currently costing circa £9m p/a)
• proactively respond to large-scale planning applications for new developments to ensure health requirements continue to be met
• improving alignment with local authority’s infrastructure delivery plans (IDPs)
• enabling other ICB delivery programmes
• introducing ‘smarter’ ways of working across our practices and estates
• driving greener, net-zero carbon ambitions 

Next steps will include scoping and prioritisation of projects with boroughs and local authorities that are required in order to meet our strategic ambitions, the development of an agreed programme architecture and associated governance requirements, and project delivery plans. A quarterly estates programme board will be held with key ICS stakeholders to monitor ongoing progress and delivery.

Work is underway with local authorities and NHS stakeholders to inform the eight infrastructure delivery plans, ensuring alignment to our overarching strategic ICS priorities and population needs. ICB estates continue to work with partners and local authorities to review available and expiring s106 (a developer contribution) and CIL (Community Infrastructure Levy) funding. So far, significant sums are in the process of being secured and allocated to estates activity. The ICB is working with local authorities, borough teams/Trusts and NHS property companies to review further opportunities to bid for CIL funding to support estates projects, and submit collective asks.

Expressions of interest for 24/25 London Improvement Grant (LIG) funding closed on November 2023, which offers funding for primary care to improve the condition of premises on an annual basis. The ICB will now work with NHSE to review and prioritise bids against the NHS’s cost premises directions and our overarching estates strategy.

A new community diagnostic centre (CDC) at Willesden Centre for Health is now complete. This new facility forms part of a wider hub and spoke model being delivered across Wembley (due for delivery in early 2024) and Ealing. Refurbishment works at Belmont Health Centre will complete this month. This project will improve the fitness-for-purpose of the premises, support the integration of practices and, like the CDC, help to reduce void costs.

The Brent Health Matters (BHM) pharmacy team were shortlisted for HSJ 2023 awards in category of Medicines, pharmacy and prescribing initiative of the year a ‘record-breaking’ 1,456 nomination entries were received for this year’s awards. The nomination ‘Mind The Gap: The pharmacist’s role in reducing health inequalities’ reflects the fantastic impact pharmacists have on reducing health inequalities by supporting people to get the most from their medicines and stay well.

By engaging with patients who are “lost” in the system, either through non-engagement or other reasons, the team builds a rapport and tailors healthcare to individual needs via a holistic approach. Through effective signposting, the team continually strives to close the ever-increasing gap on health inequality. As BHM pharmacists, they provide medicines reconciliation, structured medication reviews and medicines support services to patients.

There are huge cost-savings attributed to the work that the team do. For example, stopping unnecessary medications, prescribing more cost-effective medications, and informing GP practices of major non-adherence all contributes to saving money and improving the quality of life of patients.

World COPD Day engagement events – 15 November

NW London ICB’s respiratory team worked with the Ealing pulmonary rehabilitation team to arrange World COPD Day engagement events at Ealing Hospital and outside the Greenford Tesco on 15 November.  The events were well attended by members of the public, patients and clinical staff and they received resources and advice about COPD management, the benefits of pulmonary rehabilitation and smoking cessation. One of the patients reported that “the team was helpful in providing her with more information about her condition and advice on how to access a referral to the pulmonary rehab service to improve her health”. Ealing GP practices supported the events by sending text messages to their patients alerting them of the promotion.

High intensity user pathway 

Ealing’s new high-intensity user pathway was launched this month with multi-disciplinary meetings taking place in the Southall and North Ealing localities, attended by members of the locality’s integrated neighbourhood teams (INTs). This pathway has been set up to support patients who have been identified as very frequent users of health and/or social care services, and who require more proactive support and care planning from multiple agencies within the health and social care system. The pathway takes a holistic approach to assessing these patient’s needs, to focus on their overall health, including their physical, psychological and social wellbeing. The aim of the pathway is to reduce avoidable attendances in primary, community and secondary care whilst improving the experience of care for these patients.

Outreach at interim accommodation centres (IAC) for asylum seekers in Ealing Ealing has four IAC hotels with 639 residents as of November, 70 per cent of these residents have been in the hotels for over six months.  On the 14 November the Ealing team arranged a very successful outreach event to take more proactive healthcare interventions to the hotel in Acton. As a result of partnership approach we were able to undertake 70 health checks (including BMI, hypertension and diabetic screening), 44 lung function screenings, 14 smoking cessation referrals, and working with partners in the digital programme, distributed 8 pre-paid mobile sims (6 months free and the £5 per month) to the residents. 

Care homes summit  

One of the actions from the winter discharge schemes discussions was to listen to care homes about their challenges especially in managing patients with challenging behaviour. We organised Ealing care homes summit on 14 Nov to hear care homes challenges, current available support and what’s planned for future. It was well attended. The discussions between BBP partners and care homes providers were extremely open and honest. All partners had engaged well, had positive discussions and came up with clear actions to follow up in the next summit. The findings from the care homes summit were discussed in the steering group meeting on Thursday 28 Nov.’23 to agree an action plan with BBP partners. Next summit will be scheduled in the next few weeks to co-design and agree the support with care home providers.

Winter schemes 

Ealing BBP is currently monitoring the performance of five discharge schemes against planned. ‘Home and Settle’ and the ‘Care Home Liaison Service’ will start in near future. Work is underway to analyse the current activity and reprioritise potentially unused funding to expand the scope of schemes supporting discharges for Ealing patients in NW London.  

Core20Plus5

A member of the ICB in Ealing has been selected to be part of the Core20plus5 ambassador 12-month long program, a prestigious opportunity recognising leaders in their respective fields. 

Enhanced service offer for Hillingdon

Following the launch of the NW London enhanced service (ES) offer, there has been a positive uptake of key services with a marked improvement in delivery shown in the M7 data set for all services. 

This includes: spirometry, wound care, ECG, latent TB testing and Near Patient Testing.  Latent TB testing increased from 49.1% in M6 to 73.1% in M7 and near patient testing from 298.5% in M6 to 350.2% in M7. The borough team continue to work with the PCNs to monitor data activity and data quality. Regular good practice communication is shared with the PCNs. 

Learning disability annual health checks

Hillingdon has seen a marked improvement in performance has improved from 15.5% to 36%.  Key actions: GPs continue to build on the work from Covid-19 to support people with learning disabilities (LD). CNWL LD team work with LD health champions, PCNs and the local authority to support with annual checks. The LA have also included LD health checks as a KPI in provider contracts. 

Hillingdon Section 117 project

The Hillingdon S117 project was initiated in 2018 due to concerns regarding the significant time staff spent on completing individual case cost matrix templates and attending panels, rather than providing direct support to individuals. It was acknowledged that updates to the S117 processes and procedures were necessary. 

At the close of 2019, the initial phase of the project was concluded with an audit of over 100 cases, commissioned by London Borough of Hillingdon (LBH) and led by an independent organisation. The audit resulted in the abandonment of the cost matrix, and partners agreed to a cost split of 38% for health and 62% for the local authority, aligning with other area agreements.

Phase two of the project commenced in January 2023, achieving the following milestones:

• Establishment of the S117 standard operating procedure. 
• Creation of a process ensuring the routine identification of S117 cases through current forums where patient discussions take place.
• Cleansing of all joint S117 data, confirming the accuracy of both local authority and ICB cases, cross-checking individual cases across different datasets such as SystmOne and NHS Spine, revealing over 800 joint S117 cases, double the initially identified 400 cases.
• Inclusion of all S117 cases on Caretrack and collaboration with ICB finance teams to ensure correct updates of care packages on both LBH and ICB systems.
• Development of a process to ensure that S117 aftercare plans are recorded in both LA and Caretrack, including designated review dates.
• Implementation of a process to monitor S117 aftercare plans, with any amendments or changes being recorded and agreed upon by both the LBH and ICB.
• Looking ahead, the focus will shift to reviews in the coming months. 

Addressing health Inequalities

Harrow is committed to addressing health inequalities and improving outcomes for our residents. We are working to address the poor outcomes experienced by young black men with access, experience and outcomes, in mental health services. To address this longstanding issue we have commissioned three projects which have a slightly different focus that target young black men ranging from 16-35 years’ old. The three strands are: 

Prevention: RESTORE – weekly sports based intervention and mentoring programme: 

• ‘Convo's opened up real talk about mental health. Having those talks with my guys who get what I'm going through— hits different. Makes the whole mental health thing way more relatable’ young person in the project

EEC – eight-week psychological informed teaching sessions on racism, mental health and resilience: 

• Following engagement with the programme, participants reported that they were ‘better able to identify how they embody stress and respond to it with the tools learned.’

Finding rhythms – 12-week collaborative music-making courses:

• The programme supervisor has reported that ‘each week, they are seeing the men growing in confidence, and their ability to express themselves has already started to increase.’

The projects have been running for about five months but already, qualitative feedback from participants and the Leads has been positive. They have given insights into why young black men do not access support in a timely way, and what works to keep young men engaged and feeling supported to improve experience and outcomes. This programme of work provides support to the patient carer racial equality framework (PCREF) that is being led across Central and North West London NHS Trust.

Diabetes engagement

Working across the borough we have received 873 responses to our diabetes survey. We wanted to hear from patients with diabetes who used the service at West Middlesex Hospital, particularly those with protected characteristics and those who may use the service in the future, particularly those from black and minority ethnic backgrounds.

Lung health checks with RM Partners

Following on from the cancer update above, the targeted lung health checks programme is live in Hounslow. Patients aged 55-74, with any history of smoking are being offered a free NHS lung health check followed by a low dose CT if required. 

Eligible patients from any participating practice in Hounslow can self-refer ahead of receiving an invite. Visit the website for more information.

Hounslow borough awarded dementia friendly community status

The partnership is pleased to announce that it has been awarded dementia friendly community status by The Alzheimer’s Society.

Hounslow joins 433 communities across the country who have earned the dementia friendly title. The award citation states Hounslow Council and its partners are working to: “empower people with dementia to have high aspirations, confident in the knowledge that they can contribute and participate in activities that are meaningful to them.”

Earlier this year health and care partners, across the borough, joined with the business community and residents to create the Dementia Action Alliance. The alliance ensures that people living with dementia and their carers are understood, respected and supported. It also works with people living with dementia and their carers to understand how services for them can be improved.

Hounslow Borough Based Partnership (BBP) launches population health management framework (PHMF) Training campaign

On 1 November the Hounslow BBP launched their new population health management framework training campaign designed to get more colleagues from across the partnership trained in PHMF. 

The population health management framework (PHMF) helps to:

• Use data and engagement to understand the needs of Hounslow residents
• Identify and target those who will benefit most from interventions
• Develop evidence-based interventions
• Embed evaluation to understand impact. 

Since launching, 23 staff members have completed the first initial round of training sessions, and spaces are getting booked for December through to February 2024. 

Cardiovascular disease (CVD) workstream

The carers with CVD/ at risk of CVD workstream under the BBP’s CVD project is working to:

• Identify how well carers with a CVD diagnosis / at risk of developing CVD are accessing services- both clinical and non-clinical.
• Detect carers with CVD/at high risk of CVD through community outreach work including engagement with carers networks/ support groups and ensure they are signposted to relevant support services. 
• Increase health promotion and education for this population cohort, raising awareness and understanding of CVD and its impact on their health and well-being.

We expect to implement the engagement plan during the period Jan 24- Mar 24 following which we shall report on the findings and an action plan for the BBP’s consideration.

This month H&F hosted another successful patient reference group, chaired by local resident Peter Hamm. We had a busy agenda talking about access to services including primary care and also access to acute provision and how systems are changing to deliver advice and guidance to patients prior to referral and whilst waiting for treatment. We were joined by staff from local primary care and Imperial. In addition, we were joined by the carers network, sharing information about what they do and how carers are supported in the borough. 

Our operational delivery group meeting had a focus on co production which was really well received by system partners and colleagues. We are also discussing with action on disability the opportunities to firm up our commitment to co-production in our priority work streams 

The borough also held the first event in the latest round of feedback and engagement on the palliative care work taking place across NW London. The event was hosted by Jane Wheeler and well attended. 

The Bi-Borough health and wellbeing strategy launch – and development of Integrated neighbourhood teams (INTs) and vibrant healthy communities to help us deliver

The two boroughs launched a new Health and Wellbeing Strategy that was co-designed over a 12-month period with residents, community groups, staff and partner organisations. The strategy allows Bi-Borough Place Based Partnership to set out the 10 big ambitions and bring together health and care – and wider health determinant strategies locally. The strategy creates a delivery framework that brings together our local partnership working with our communities, NHS, local authority, VCSE and public service partners.   The strategy also includes an emerging outcomes framework that will help us prioritise our delivery plans for 24/25 and 25/26. Click here for additional details.

Integrated neighbourhood teams (INTs) are the key ‘delivery vehicle’ for our strategy. All three of the integrated neighbourhood teams covering the Westminster and Kensington & Chelsea now have leadership teams in place and a set of initial priorities areas to focus upon:

• North Kensington & Chelsea and Queen’s Park & Paddington – with initial focus on supporting people 65 years and over, including Mental Health needs 
• South Kensington & Chelsea – supporting children and young people, including through family hubs, and development of community connectors programme
• Westminster – supporting people 65yrs and over, and Octopus community connectors programme

In addition, the partners within the INTs are also launching organisation development programmes which include: workforce, estates, communications, digital and information governance.   

Vibrant and healthy communities is a programme led by our local voluntary and community sector (VCS) organisations with the primary focus of empowering communities to reduce health inequities – an integral delivery vehicle for our partnership.  In November, our local voluntary sector partners held a “Doing things differently” workshop with over 45 community organisations represented to co-produce and deliver our health and wellbeing strategy. The launch allowed us develop the community-led delivery plans for 24/25 and 25/26 that included:

• Building strong relationships and collaborative culture between the voluntary and community sector and the NHS
• Building a holistic approach with focus on people, early intervention, and prevention to reduce health inequalities
• Strategies to maximise use of VCS assets, like data, insight, and expertise
• Develop VCS capacity and infrastructure for partnership working