The Case for Change
The six South West London CCGs recently published a five year strategy to address the clinical and financial challenges facing the local NHS.
This section sets out some of the key aspects of 1) the case for change and 2) the five year strategy.
The six local clinical commissioning groups (CCGs) – Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth – are working in partnership with NHS England as ‘South West London Collaborative Commissioning’. They have developed a five-year strategy for local health services, which was published in June. The strategy sets out the direction of travel for local health services and what they should achieve over the next five years. It does not contain any proposals for specific sites or trusts. The next step is to agree the detail of how the strategy will be implemented, including the role of each local Hospital and Community provider trust in delivering it. This will be discussed with the trusts and local Health and Wellbeing Boards once the strategy is approved and our implementation plan will be published in due course.
Why do services need to change?
The strategy was developed in response to NHS England’s ‘Call to Action’, which highlighted the clinical and financial challenges faced by the NHS nationally and called on CCGs to draw up local plans to address these challenges. (There have been previous attempts to address these issues which did not go forward; most recently the Better Services Better Value review of hospital services, which the CCGs inherited and decided not to continue.) In south west London, the challenges are similar to elsewhere. CCGs have identified the following challenges.
- Safety and quality standards. The quality and safety of healthcare and the outcomes for patients vary enormously depending on the time and place that services are accessed.
- None of our acute hospitals meets all of the London Quality Standards (LQS), which are minimum safety standards supported by all 32 London CCGs and are designed to improve patient care and outcomes. The standards require London trusts to provide consultant-delivered services seven days a week, including evenings and weekends. All London acute hospitals are working towards the LQS. There is evidence that failure to provide consultant-led care compromises patient safety, with between 400-500 deaths in London each year attributed to patients not being able to see a consultant in the evening or at weekends.
- Mental health services often fail to provide support at an early enough stage, leading to service users becoming more seriously unwell and having to be admitted to a mental health hospital. Had they been treated sooner, they could have avoided hospital admission.
- General practice needs to be transformed, so that GP practices work together and coordinate patient care across their area. Community services also need to meet the highest standards and to work more closely with primary care, mental health and acute hospital services, and more closely with social care.
- Workforce gap. There isa national shortage of specialist staff, so getting the right workforce is a major challenge. For example, there are not enough consultants available to meet the London Quality Standards across all our hospitals and this makes our services less safe for patients.
- Financial gap. While NHS spending has not been cut, the costs of providing care are rising every year due to rapidly increasing demand from a rising and ageing population. Current analysis shows that the combined income of our 6 CCGs in south west London over the next five years is about £1.873 billion, while the costs of commissioning the services we currently provide is expected to be £2.019 billion. In addition, the running costs of the CCGs are expected to be about £45 million and CCGs are required to produce a 1% surplus, adding a further £19 million cost. This means that if we do nothing, the CCGs in south west London will face a financial deficit of £210 million by 2018/19. (See diagram below).
- In addition, the local hospitals have identified a combined total of £360 million worth of savings which they think they need to make to balance their own books. The reality is that we face a stark choice between making change that is planned and agreed by local clinicians or some services becoming clinically and financially unsustainable – which will ultimately lead to changes over which we have no control.
- Rising demand for healthcare. Our population is growing at one of the fastest rates in the country, meaning large increases in demand for maternity and paediatric care as well as for older people. Our ageing population, in which more people are living with long term illnesses like diabetes and heart disease, means there is a need to provide much more care outside hospital. Similarly, much more children’s care needs take place outside hospital, as do antenatal and post-natal care for pregnant women. This means we need to shift resources from hospitals to community services – an issue that has been recognised as a challenge across the NHS for several years.
What does the five year strategy say?
The strategy has four aims: to raise safety and quality standards, to address the financial gap, to address the workforce gap and to confront rising demand for healthcare.
Key headlines from the strategy include:
- Standards matter. The standards that we are asking of our providers are all about improving care and outcomes for patients – for example, ensuring consultant presence on hospital wards, which has been shown to improve patient and outcomes and to save lives in emergencies. We need consultant presence on the wards seven days a week, in A&E for a minimum of 16 hours a day and on labour wards 168 hours each week (24/7).
- We need to change the way we deliver health services to meet the changing needs of an ageing population in which many more people live with long term conditions. This means we need to spend more money on services based in the community, keeping people out of hospital unless they really need to be there. Nationally, £3.8 billion (locally around £85 million) is being moved from hospital budgets to focus on better integration between health and social care through the Better Care Fund.
- We will meet 100% of the London Quality Standards (LQS) by 2018/19 and many of them before that. We will ensure seven-day services are delivered by 2015/16. This requires a collective approach across south west London. The LQS set out what good care should look like and they were developed to ensure that all hospital-based acute emergency and maternity services provide care that is safe and of consistently high quality for patients across London, seven days a week. They were developed by clinicians and patients working together and are based on existing evidence-based standards from Royal Colleges, the College of Emergency Medicine and other professional bodies. They were endorsed by the London Clinical Senate and the London Clinical Commissioning Council. All 32 London CCGs are committed to achieving the standards, which will improve the safety of hospital services and improve patient care.
- The LQS are non-negotiable priorities for NHS hospitals in London. None of our acute Trusts currently meets all of the standards and there is substantial variation in the quality of care provided across local health services. Nor are there enough consultants to deliver the LQS across four hospitals. This is why we believe change is needed, but we would like to talk to local hospital trusts about the best way of making the changes.
- Community-based services must meet the highest possible standards and should be networked with each other and other health and social care services. All six CCGs have made huge progress on developing their plans to improve care outside hospital – the strategy includes details of their plans for better integrated care outside hospital, meaning that hospitals will in future deliver fewer services as more are delivered in the community.
- We need to transform primary care, with networks of practices working together to coordinate patient care.
- Mental health services need to be reshaped so that they achieve the highest possible standards and are focused primarily in the community, working in an integrated way with physical health services, local authorities and the voluntary sector.
- Most planned operations in south west London requiring an overnight stay will take place in a planned care centre within five years, with urology services identified as a potential pilot.
- Better information for patients about where to access health services is critical to our success and that is why we need to do more to help patients to choose the right service.
- Working together is critical to our success: our services are inter-dependent and the challenges we face cross borough boundaries. We do not believe it would be possible to achieve the scale of change that is needed by working independently at borough level. This is why the six CCGs and NHS England are working as one strategic planning group.
- The NHS budget is not expected to increase, but the costs are rising much faster than the rate of inflation. It is important that any changes we make are planned, rather than happening due to services running into financial difficulty.
- The five-year strategy sets out the direction of travel for the local NHS and the standards of care that we want for our patients. How we get there is the next step. We will now work with provider trusts, Health and Wellbeing Boards and patient representative groups on the detail of how we get there and what it means for each trust.
- The strategy is to be implemented over a five-year period and ‘milestone’ plans are being agreed for each clinical area. The timescales for agreeing an implementation plan are under discussion as part of our dialogue with provider trusts.
- Should the outcome of our discussions with providers and Health and Wellbeing Boards mean major service change at any of our Trusts, then proposals would of course be subject to public consultation.
What would happen if we didn’t make any changes?
- Without change, the local NHS is likely to run out of money and face intervention at national level, as happened in south east London. Projections for the next five years show that if we continue as we are, CCGs will face a deficit of £210 million by 2018/19. This means we would not have the money to continue to commission the services we do now and those services would start to decline.
- We would not be able to implement the London Quality Standards in our hospitals. Patients would continue to receive sub-optimal hospital care at weekends and in the evenings, when most care falls to junior doctors. This would mean lives continued to be lost that could have been saved.
- We would not be able to care properly for the large proportion of our patients who are elderly and/or living with long term conditions. There is only one pot of money, so delivering better care in the community, in GP surgeries and in people’s homes, means shifting resources that are currently tied up in hospitals.
How can the NHS improve services and cut costs at the same time?
Clinicians have long recognised that if health services were better organised and delivered differently, they could be both better and cheaper. The way in which NHS funding works means that hospital care is expensive, even if it is a service that could be delivered better in a GP surgery or other community setting. It is also an inefficient way of providing care that could be organised more locally.
On a bigger scale, London’s reconfiguration of stroke, major trauma and heart attack services has transformed outcomes in these areas from among the worst in the country to the best. Ambulances drive patients past the nearest hospitals to specialist centres, where several consultants and the best hi-tech equipment are on hand to treat them. While most patients travel further, many more survive than used to be the case – and the services are also cheaper to provide.
If you have questions or want to know more about any aspect of the CCGs’ strategy, you can email the programme team at firstname.lastname@example.org or contact your local CCG.
You can follow @swlccgs on Twitter or visit our website, www.swlccgs.nhs.uk