NHS Hillingdon was abolished on 1st April 2013, when Hillingdon Clinical Commissioning Group became responsible for commissioning NHS services for Hillingdon residents. Hillingdon Health and Wellbeing Board also became responsible for setting the strategy for Hillingdon's NHS services and for integration of health and social services.
- Perinatal services: Additional capacity for women with prenatal mental health problems
- Children’s services: Additional capacity to promote the mental health of children.
- Child and Adolescent Mental Health Services (CAMHS): Waiting times of 52 weeks have reduced. 61% of patients are now waiting less than 18 weeks. The CAMHS Out of Hours service is not yet live but recruitment started in September 2015.
- Dementia: Improved access to Memory Assessment services. Waiting times are 3 - 6 weeks.
- Improving Access to Psychological Therapies (IAPT): Enhanced capacity has increased access to services, with both self referral and GP referral options, including older people and people with long-term conditions.
- Psychiatric liaison service in A&E: Patients now have access to psychiatric assessment within four hours , with urgent cases seen within one hour.
- Urgent care pathways: The mental health urgent care crisis line commenced on 3rd November with a single point of access and 24/7 timely assessment
- Other planned developments: Recruitment has commenced for an eating disorders Service. An interim service model and business case for a Learning Disability Community Service were to be completed by the end of November 2015. A business case is being developed for January 2016 aimed at reducing admissions from care homes as a result of complex challenging behaviour..
- According to Census 2011, there were over 25,000 carers in Hillingdon providing unpaid support to patients.
- The cost to carers can be considerable in terms of their own health, financial situation, employment, and independence. Good progress has been made in the delivery plan of new initiatives such as the Carers Recognition Scheme and the Carers Support Planning Checklist.
- Communications: a joint campaign between the council and Hillingdon CCG is being drafted to encourage carers to access services to assist them in their caring role . This will include posters, media articles and online case studies.
- Lloyds Bank Uxbridge are delivering workshops for young adult carers during September to December 2015 covering budgeting, financial management and workplace interviews.
Part I: Notes from the papers1. “Hillingdon4All”: This is a one year service pilot to simplify access to services for older people, particularly those with frailty factors, including social isolation. It is a whole systems model of care for 4,800 people, aiming to provide a single point of access to extensive preventive services from third sector organisations, social services and primary healthcare. It builds on similar national projects.
3. Chronic pain service: Extension of this service is now being planned.
4. “Like Minded”, a NW London Mental Health and Wellbeing Strategy: This strategy has been agreed across eight boroughs which allows provision of services needing a large population, eg the new community eating disorder service for young people which needs a population of 500,000+.
5. Registered Nurse and Midwife Revalidation: Revalidation at three year intervals will require evidence of a range of factors to show that the individual is keeping up to date and getting current practice. The new requirements come into force in April 2016.
6. Mental Health Assessment Lounge at Riverside, on the Hillingdon Hospital site: Patients in the Emergency Department of Hillingdon Hospital needing a calm environment for lengthy mental health assessment can be transferred to this Central & North West London FT’s facility, which has benefitted both patients and the Emergency Department. It was agreed that this service continue.
7. Shaping a Healthier Future Strategy: CCGs have agreed cost sharing arrangements for this programme, which is being developed and updated to provide better care for two million people.
2. Capital funding for IT for GPs: The CCG’s original bid for this funding in 2015/16 was £356k which was unsuccessful. However NHS England has now approved an award of £230k. The CCG is obliged to prioritise the needs of local GPs. 36 practices need server or software upgrades. PC, printer and scanner upgrades are also needed, some of which can be funded from 2014/15 capital. All practices are being moved to routine use of NHS Mail, which provides protection for transmission of patient identifiable data.
3. Tuberculosis screening: Across the country, NHS England and Public Health England are starting to implement a programme to screen new immigrants from high prevalence areas of the world. The local bid for £804,155 is to set up prospective screening of new registrants and retrospective screening of eligible patients who have registered in the last four years. A local TB Steering Group has been set up with local TB specialists, pathology, Public Health, a lead GP and a project manager.
4. Children and Adolescent Mental Health Services: NHS England is providing £250m per year for 5 years to improve these services nationally. This responds to the national rise in recent years in the number of young people experiencing mental health issues. Hillingdon has been awarded £149,760 per year for CAMHS Community Eating Disorders and £374,863 per year for CAMHS Service Transformation. All Local Transformation Plans will be assured by NHS England and the process will be backed by a programme of regional and national support.
5. Provision of a hearing loop in the CCG Boardroom: In response to a question by The Community Voice, the CCG announced that it hopes to install a loop system by the end of the year.
6. Finance: A surplus of £3.82m is predicted, most of which is from last year’s surplus of £3.33m.
Integrated Diabetes Care: Over 16,000 Hillingdon people are registered with a diabetes diagnosis, 6.4%, which is higher than London (6%) and England (6.2%), but it is estimated that one in four people in London is undiagnosed. Integrated care of these patients is to be developed with existing providers.
Wheelchair Service: Opcare has been awarded a contract for provision of wheelchairs in Hillingdon and Harrow, which is expected to save Hillingdon CCG £100k in the first year and Harrow CCG £75k.
North West London Mental Health and Wellbeing Strategy: Eight Boroughs are working with service user groups to prioritise workstreams.
Memory Assessment Service: Dementia diagnosis currently reaches only 57% (target 67%). Two dementia nurses are to be appointed to focus on assessments, not treatment, and, in conjunction with the Alzheimer’s Society, a specialist dementia adviser to provide post diagnosis support, plus 0.4 whole time equivalent psychiatry input and additional administrative support.
Integrated care for older people: Five voluntary organisations co-operate to provide targeted care – Hillingdon Age UK, Hillingdon Carers, DASH, MIND and Harlington Hospice with:
- One phone number
- Work with GP Networks
- Local knowledge and expertise
- Patient Activation Measure (PAM) – a tool to target support at those most able to benefit
Hillingdon’s Key Health factors: It has 46 GP practices, 42 dental practices, 62 pharmacies, 47 ophthalmic practices. 32% of Hillingdon people are from black and ethnic minority communities. Both young (5–19 years) and old (50+) are larger groups than London, but smaller than England. Some areas fall in the 20% most deprived nationally with a significant number with children living in poverty.
Hillingdon’s key health trends
- Population growth in Hillingdon is low, around 0.6% a year, but the majority of growth is in the elderly population, with more need for health and social services.
- Dementia is expected to increase by 7% over 5 years.
- 3.8% of households are expected to have frail elderly members needing support and 29% of these will be in unsuitable housing.
- Childhood obesity is rising, with 20% of Year 6 children classified obese and likely to suffer cardiovascular disease in time ahead.
- More alcohol related hospital admissions than England – men 19% more, women 9% more.
Finance: In July, latest month available, the CCG was achieving its year to date planned surplus and it expects a surplus on Programme Budgets of £3.482m at year end, March 2016 - which includes the £3.33m surplus from last year - and to break even on running costs .
Integrated performance: Most services are on target but the CCG has underperformed on cancellations of podiatry appointments and the wheelchair service. Ultrasound appointments are taking over six weeks.
Shared Care Records: Work is ongoing. Hillingdon is to be a pilot site for NW London.
Annual Accounts for 2014: These noted that Hillingdon CCG inherited an underlying deficit of £13m in March 2013. The out-turn for 2014/15 is a surplus of £3.3m, carried forward to 2015/16, which was assisted by in-year allocations, slippage on investment plans and non-recurrent underspends. There remained an underlying deficit of £7.7m which will need to be addressed in 2015/16.
- 1. Mental Health Urgent Care: There is currently no coherent mental health urgent care pathway in Hillingdon, which leads to delays for service users. Patients often use Accident & Emergency services at Hillingdon Hospital for crisis care. The new pathway, if approved, from 1st October 2015 will deliver a single point of entry for three Outer London Boroughs, Brent, Harrow and Hillingdon, with an enhanced Home Treatment Crisis Response Team for each Borough providing an urgent response within four hours, 24 hours a day / 7 days a week. Two extra staff per Borough will be employed from 0800 to 2200 and two extra staff per inner and outer hub from 2200 to 0800 hours. CNWL will provide £1.98m to support the proposal and in a full year (2016/17) Hillingdon CCG will provide £357k.
- 2. Aftercare policy for people who have been detained under Section 117 of the Mental Health Act: The Act carries a duty for CCGs and Social Services to support patients after discharge from hospital until they no longer need such services, but Hillingdon CCH and the Local Authority do not currently have an agreed policy for joint funding of these services. Options for an agreed policy are now being explored.
- 3. Finance Report for June 2015: The CCG was slightly better than plan with a surplus of £0.902m against a plan of £0.870m. The CCG expects to meet its planned surplus of £3.482m at year end in March 2016, providing it receives expected allocations from North West London and expenditure is in line with plans.
- 4. Integrated Care Planning: Hillingdon Care Community has applied to be one of six early adopters in a pilot developing a joined-up patient record across all care settings, which will be available to patients and support direct care. The pilot will initially support the 17 practices in North Hillingdon and the care providers involved in the whole systems integrated care programme for over 65s. If successful the system will be deployed across the whole of Hillingdon.
- 5. Use of North West London Mental Health Transformation Funds: The purpose of this fund is to support the work programme of the NWL Mental Health and Well Being Strategic Implementation and Evaluation Board and to enable local implementation of its key priorities. Hillingdon CCG will receive £135,783 for a variety of purposes, including shifting settings of care, urgent assessment and care, dementia and perinatal services.
- 6. Shaping a Healthier Future: Changes must be made to the Business Case by August 2015 to ensure that the timescale of the implementation programme delivers changes by May 2019, ahead of the next General Election.
- 7. Primary Care Workforce Plan for 2015-16: This plan sets out the picture of primary care staffing to sustain quality general practice and to develop leaders of integrated models of care delivery. The plan will address gaps in both workforce numbers and sufficient skills for provision of more out of hospital services, as well as developing new roles for new models of care.
- Policy on referrals within hospitals: The eight NW London CCGs have a joint policy on these referrals referring patients back to their GPs for further action where possible, but a number of exclusions on clinical grounds permit immediate internal referrals if necessary.
- Winter Resilience Funding: Hillingdon CCG has received £1.6m from NHS England and it has allocated £400k internally, making a total of £2m already allocated to combat winter pressures 2015/16 + further cash set aside in case pressures are worse than expected.
- CNWL CQC inspection report: The overall rating was “Requires improvement” but Caring was rated as “Outstanding” and Well Led was rated “Good”. In Hillingdon, Sexual Health Services were rated “Outstanding”, but Acute Mental Health Adult Wards of Working Age and Psychiatric Intensive Care were rated “Inadequate”.
- Primary Care Co-Commissioning: All eight NW London CCGs are involving their Health and Wellbeing Boards in how to engage in co-commissioning with NHS England in future.
- National measures about payments to senior NHS staff above the Prime Minister’s £142.5k per year: No NHS staff in Hillingdon are paid at that level.
- Integrated Cardiology Service: A new Business Case was agreed. Death rates from premature cardiovascular disease have fallen by around 50% in the last ten years, but an increasing number of patients are living with chronic cardiovascular disease.
- Empowered Patient programme: The current programme covers diabetes, COPD and asthma self-management workshops for 900 patients – this is to be extended to 2900 patients with various conditions, with the hope of gross savings of over £276k.
- Finance: Hillingdon CCG is now forecasting a surplus in March 2016 of £3.84m on Programme Budgets and break even on Running Cost Budgets, in line with the CCG’s plan. This is after application of £3m transitional support for the forecast over-performance of acute services and the marginal rate of 45% above the Guaranteed Minimal Sum for the contract with Hillingdon Hospital FT.
- London Ambulance Service: A diagnostic review has shown that the amount of time LAS ambulances are in active use is around 90%, whereas other ambulance providers outside London average 70-74%. The review concluded that to improve performance LAS utilisation needs to be reduced and staffing levels increased.
Finances: Final accounts for 2014-15 are being prepared and will be published later, but the CCG believes it had an in-year surplus of £3.3m, the first surplus recorded by the CCG or for many previous years by the former local commissioners, Hillingdon Primary Care Trust. This success was achieved with the help of transitional support, slippage on investment plans and non-recurrent underspends. The CCG’s underlying deficit was £7.7m.
Acute services: Some targets were not reached in February, the latest month for which data was available:
- Ambulance handovers at Accident & Emergency Departments: There were many delays, breaching targets
- Cancer targets: Some targets were not met
- Infection control: The MRSA target was narrowly missed
Integrated Appraisal Team: The purpose of this team, drawn from The Hillingdon Hospitals NHS FT, the Hillingdon Clinical Commissioning Group, the Continuing Healthcare Team, and the London Borough of Hillingdon (LBH). Is to appraise patients on admission to acute care and to identify their care needs in order to facilitate their care on discharge, regardless of whether they are funded by LBH, the NHS, or are self-funding. This team will include a discharge co-ordinator, senior social worker, nurse assessor for continuing care, occupational therapist, community care worker and administrators. The team will be established and the provision implemented over a period of four months from May 2015.
Mental Health Care: Hillingdon CCG and the London Borough of Hillingdon’s Joint Mental Health Plan for 2013-16 set up a number of planning groups and other initiatives in 2014-15 and priorities are being set for 2015-16. Also there is a national commitment to ensure that CCGs are focused on improving mental health as well as physical health, with comparable financial investment.
Carers strategy 2015-18: The Care Act 2014 requires local authorities to identify carers’ unmet needs as part of their preventative responsibilities and a duty on NHS bodies to co-operate with local authorities on this issue. The 2011 census showed over 25,000 carers in Hillingdon providing unpaid support. Consultation with carers has shown that they want:
- A wider variety of respite opportunities
- Assistance and advice on finances and benefits
- Greater flexibility for GP and hospital appointments
- One to one support
Proposed use of funds withheld from hospitals for re-admitted patients: CCGs are entitled to withhold payment to Acute Trusts for emergency re-admission of some categories of patients within 30 days of their discharge. In 2015-16 a sum of £1.4m is thus available for allocation and it is proposed that the following processes are supported:
- Discharge planning process
- Post discharge care / support
- Daily review of readmissions
- Review of Emergency Department procedures
- Support for the urgent care system with winter pressures.
The notes below are not a summary of the meeting, only items of particular interest.
1. Primary Care Co-commissioning: The CCG’s membership voted on 4th March to seek this status, which has now been agreed with NHS England. This expanded role will allow money to be more readily shifted around the local health service economy and improve local services. The risk of conflicts of interest is addressed by the NHS England Statutory Guidance for CCGs.
2. Finances: The CCG now forecasts a £2,692k surplus at year end on Programme Budget and £508k surplus on running costs. The underlying position at month 11 is a deficit of £7.7m which compares with the planned underlying position for 2014/15 which was to be in recurrent balance. The deterioration relates largely to Acute over-performance and shortfall in savings, offset in year by non-recurrent allocations, slippage on investment plans and non-recurrent under-spends.
3. Budget 2015-16: In December 2014 NHS England confirmed that Hillingdon CCG was assessed as 7.7% below its target allocation and it therefore received a higher than average increase for 2015-16 of 7.6%. On this alone, the CCG’s 2015/16 financial plan would be a deficit, but the application of the NW London financial strategy provides an additional £8.8m, moving the CCG’s underlying position from a deficit of £7.7m to a surplus of £3.3m. On that basis a budget has been set for 2015-16, which is subject to approval from NHS England.
- Accident & Emergency: Four hour target wait in A&E not met for 5th consecutive month, exacerbated by increased emergency admissions and increased length of stay leading to bed capacity issues. However, the Acute Medical Unit opened at Hillingdon Hospital in December 2014 provides 31 beds and mitigates the problem as does an additional elderly care consultant and the expansion of the Ambulatory Emergency Care service.
- London Ambulance Service: Paramedic levels are understaffed. This and slow hospital handover times contribute to the failure of LAS to reach callers within target times .
- NHS 111 ‘phone service: Call back problems have caused concern. A recruitment programme is in place to recruit more clinicians to the service.
- Mental Health Services: The Improving Access to Psychological Therapies service is recruiting additional staff. Under performance - due to both a lower number of clinical sessions and to patients who do not attend - is being addressed.
5. Better Care Fund:
- Hillingdon’s BCF plan was approved without conditions by NHS England on 6th February. Now Hillingdon Council and Hillingdon CCG must formally agree the financial arrangements within the plan. The pooled fund for Hillingdon is £17.991k,which will be hosted by Hillingdon Council, operating as the equivalent of a joint bank account for 2015-16.
- The scheme’s focus is on people living with dementia, people susceptible to falls and/or socially isolated, aiming to reduce emergency admissions to acute care and admissions to long term residential care. It also supports the role of telecare, third sector providers working in the community, GP Networks in increasing dementia diagnosis rates and provision of increased support to carers and caring families, including respite care and personalised carers’ support.
- To keep people active mentally and physically it will build on partnerships with Public Health, the Library Service, the Sports and Leisure Service and the third sector.
6. Support for GP Networks: The Business Case for GP Networks support proposes £333k in 2015-16 for clinical, administrative and business manager support in 2015-16, shared between networks on a capitation basis.
7. Wheelchair service for Harrow and Hillingdon: The CCG is procuring a new Wheelchair Service which will hold agreed levels of stock with each acute trust and other key providers for short-term loan while customised wheelchairs are being arranged.
8. Community bed based provision for 2015-16: The proposal is to “block” book 5 nursing and nursing/dementia care beds from suitable care home providers for patients who need a bed based service and are medically fit for discharge from acute care.