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.
The notes below are items taken from the Board papers – not a summary of the meeting.
- 1. Better Care Fund:
The revised proposal was approved by the Hillingdon CCG and the London Borough of Hillingdon and submitted by January 9th as expected.
Plans will focus on seven schemes, below, overseen by the CCG’s Chief Operating Officer and the Council’s Director of Adult Social Care, with a consultative forum including The Hillingdon Hospitals FT and Hillingdon Healthwatch:
- Early identification of people susceptible to falls, dementia or social isolation.
- Better care at end of life
- Rapid response and intermediate care
- Seven day working
- Alignment of community services with emerging GP networks
- Care Home initiative
- 2. Primary Care Co-Commissioning:
Member practices of Hillingdon CCG are to be asked on 4th March to vote on whether to enter Joint Commissioning for Primary Care services with NHS England.
- 3. Prime Minister’s Challenge Fund:
Wave 1 funding was used in Hillingdon to establish six GP networks, two in each locality, each with a clinical lead, management lead and education lead. Work has been carried out to improve IT, allowing patients to see their records and e-prescribing. Work is underway to establish IT links to allow GPs in a network to view patient records from other practices in the network to facilitate evening or weekend access, but patients will have to give permission for this access to be granted.
- 4. Finance:
At end of month 10, January 2015, Hillingdon CCG was forecasting a surplus of £2,692k at year end, achieved with the help of non-recurrant allocations, slippage on investment plans and non-recurrent underspends. The underlying position at Month 10 is a deficit of £7.7m (£15m if 2.5% headroom is treated as recurrent)
- 5. Actions to address under-achieved perfomances:
- A&E and LAS handover delays: Contract query in place and whole system action plan agreed.
- Clostridium difficile infections: Brent Harrow Hillingdon quality team is reviewing cases. Over 50% of cases assessed as community acquired.
- Early mental health intervention services: An assessment tool is being developed to assist screening of all new referrals
- Mental health delayed transfers of care: Discharges are being expedited.
- 6. 111 Re-Procurement:
There are currently three contracts for the NHS 111 service in North West London, delivered by two different providers. The Hillingdon service is provided by Care UK. A national model is being explored and local arrangements are being extended until March 2016 to allow clarification of the national model before long-term local contracts are arranged.
- 7. Pressure Relieving Equipment:
The move to a new supplier by 31st March 2015 is expected to save the CCG upward of £300k and to protect the CCG from future claims for lost / damaged equipment. The quality has been approved by Central & North West London FT’s Tissue Viability Team and patients will receive better equipment. Feedback from patients has been used to shape the service specification.
The notes below are items of particular interest – not a summary of the meeting.
1. London Ambulance Service Strike on Monday 26th January: During the LAS strike, when capacity is expected to be reduced by one third, both the Army and the Police will be providing support for patients in urgent need of transport to Emergency Departments.
2. Finance: At end of month 9, December 2014, Hillingdon CCG was breaking even year to date, and forecasting a surplus of £703k at year end, despite an overperformance forecast on Acute contracts of £4.8m - which would equate to £11.9m without the benefit of transitional support and the marginal rate of 45% for services above the Guaranteed Minimum Sum.
(Community Voice, of which Ruislip Residents' Association is a member, has asked how savings from application of the marginal rate to Hillingdon Hospital have been used – these savings should be used for admission avoidance projects. A written response is awaited.)
3. QIPP savings: A shortfall of £2.1m is currently forecast at year end against the £10.37m Quality, Innovation, Productivity and Prevention plan. Most of the shortfall relates to reductions in non-elective activity schemes at The Hillingdon Hospitals NHS FT.
4. Performance: The CCG continues to perform well against most cancer wait targets.
Increased activity in Emergency Departments has caused poor performance, with targets missed for waiting times and emergency admissions causing bed capacity issues for planned admissions.
The London Ambulance Service has been poor for some time, failing to meet targets for even seriously ill patients. It has a significant lack of staff, urgency has increased, and delays in transfer of patients to Emergency Departments have hampered turn-around. An independent clinical review and cash input have led to a recovery plan, to be piloted in February. Multiple vehicles are no longer sent to incidents.
5. Primary Care Co-commissioning in North West London: The NW London CCGs submitted an Expression of Interest to NHS England for delegated commissioning functions, and there is a shared agreement to set up a shadow joint committee from January 2015. The CCGs seek full delegation powers for primary medical services, but it is recognised that this may end with joint commissioning, or with limited powers to advise but not to make decisions. Hillingdon Healthwatch expects observer status on any such body, but has requested full membership so that it has a right to speak at meetings. Background talks are continuing.
Today, General Practice undertakes 90% of NHS activity for 7.5% of the cost, seeing more than 320million patients nationally per year. The model of General Practice that has served London in the past is now under unprecedented strain. Therefore in NW London there is an ambition to enable a shift in investment into primary care to achieve supported and sustainable General Practice.
6. Long Term Conditions Strategy: A Long Tern Condition is defined as a health problem that cannot be cured but can be controlled by medication or other therapies. Three out of every five people aged over 60 in England have a LTC and due to the aging population the number of people with multiple LTCs is predicted to rise by a third over the next ten years . People with LTCs are the most frequent users of health services, accounting for 50% of all GP appointments and 70% of all inpatient days. Treatment and care of those with LTCs accounts for 70% of the primary and acute care budget in England. In Hillingdon there are an estimated 91,000 people with LTCs - 37,000 of them with two or more LTCs.
The focus of the Hillingdon CCG strategy is early diagnosis, supported self management, and optimising Primary and Community Services to prevent complications. The current NHS cost of LTCs in Hillingdon is estimated between £91m and £116m. For patients who also have mental problems, the cost is at least 45% greater.
7. Improving Access to Psychological Therapies: This is a NHS England programme offering interventions approved by National Institute of Health and Care Excellence (NICE) for treating people with common mental health problems including depression and anxiety disorders. In Hillingdon approx. 30,000 working aged adults have a common mental health disorder of whom over 21,000 have an element of depression. A needs assessment suggests that anxiety and depression are under-detected in Hillingdon. Service capacity needs to be increased in 2015-16 and access broadened to include self referral and greater access through non-traditional routes, which service users find less stigmatizing, such as Third Sector involvement in signposting and delivery of IAPT compliant Therapies..
8. Better Care Fund: Hillingdon CCG worked with Hillingdon Borough Officers and the agreed revised plan was submitted on 9th January 2015.
The notes below are from the Board papers - only items of high interest are noted.
1. Full authorisation: Hillingdon CCG was authorised in April 2013 with five conditions, all of which have now been met, so this CCG is now fully authorised.
2. Non-Elective activity in Hillingdon: The recent increase in activity is driving pressures in the health economy. Hillingdon CCG’s Quality, Innovation, Productivity and Prevention plans (QIPP) is expected to be £2.3m below plan and the Hillingdon Hospital Trust is close to producing a deficit at end of year. The work addressing this problem has three strands:
- Reducing the number of people attending hospital Emergency Departments
- Reducing the number of hospital admissions
- Safely reducing the length of stay of admitted patients
3. Wheelchairs: Central & North West London FT has given Harrow and Hillingdon CCGs notice that it will not repair and maintain wheelchairs after 1st April 2015. The CCGs are extending the current contracts with subcontractors by three months and seeking new arrangements. Users will be consulted.
4. Dermatology: A new Hillingdon consultant–led community service will be provided by Concordia Health Ltd. It is expected to start accepting referrals from 15th December 2014.
5. Audiology: The service previously provided for Hillingdon through the Pan London Diagnostic Services contract has now been awarded to Specsavers, which tendered at 33% below tariff. Based on the 2013/14 contract activity, this should save £28,050 per year.
6. Dementia diagnosis targets: Hillingdon is rated as red, with a 42% performance rating.
Next meeting: Friday 23rd January 2015 in Committee Room 4, Civic Centre Uxbridge
This report is not a summary of the meeting - only items of high interest are noted below.Two Questions from the public – both from The Community Voice
- Concerning Central & North West London FT’s decision to cut Hillingdon mental services unless payment is agreed by Hillingdon CCG
- The refusal of Hillingdon Health & Wellbeing Board to approve the Hillingdon Better Care Fund proposals, one of only five in England where agreement had not been reached.
Inconclusive responses were given to both questions, but the issues will be carried forward
Dementia diagnosis delay: The Community Voice question from last month was being followed up with a view to possibly increasing capacity. (CNWL had previously noted that the Hillingdon wait for dementia diagnosis was only a little longer than the national average - 7.3 weeks versus 4 to 5 weeks)
Better Care Fund Action Plan:
Failure of Hillingdon CCG and Hillingdon H&WB to reach agreement has led to the Nationally Consistent Assurance Review process to require Hillingdon CCG to pass the £833k Care Act Funding to Hillingdon Council. External support is being provided to enable revision of the BCF to identify the use of this funding. The revised BCF will be resubmitted to NCAR on 9th January 2015.
New Hillingdon CCG headquarters: The CCG moved to Boundary House Cricket Field Road
Uxbridge on 24th November. From January 2015 Governing Body meetings will be held there.
Finance Report: At month 7, October, the CCG was breaking even and forecasting break even at year end on both its Programme and Running Costs budgets.
PerformanceTargets: To achieve these targets the CCG is dependent on its large number of providers - failure by providers fails their commissioners too. So this CCG has failed many targets but there appears little cause for concern overall and it is taking appropriate action where needed.
Escalation of non-elective activity in Hillingdon: At Hillingdon Hospital activity levels have increased by 13% from 13/14 to 14/15, causing failure to reach the target of admitting or discharging 95% of patients within four hours, and causing shortage of beds due to increased admissions. Tackling this problem is underway, within three strands:
1. Reducing the number of people attending the Emergency Department
2. Reducing the number of admissions.
3. Safely reducing the length of stay for admitted patents.
Hillingdon Fracture Liaison Service: There is considerable variation in fracture treatment and outcomes across Hillingdon’s secondary and primary care. Development of the Fracture Liaison Service will enable Hillingdon CCG to be compliant with the NICE Guidance and the National Audit of falls and bone health in older people.
Perinatal Mental Health Services: 20% of pregnant women suffer these problems during or for a year after pregnancy, with risks for mother, baby and the family. A review of services is underway.
Primary Care Co-commissioning in North West London: The paper ‘Delivering Better Outcomes of Care’ was developed by the eight NWL CCGs to set out their vision for transformed care. Guidance is still emerging from NHS England, so there is still work to be done on how co-commissioning could be best used in NWL. Shadow arrangements prior to final arrangements for introduction in April 2015 will allow the CCGs to start testing proposals as they emerge.
Planned closure of maternity and related services at Ealing Hospital:
Ealing CCG has postponed until January 2015 its decision on the date to close these services.
This report is not a summary of the meeting - only items of high interest are noted below.
Questions from the public:
- A Community Voice question asked what action the Board is taking to address the assertion in a TV programme on 13th October 2014 that Harrow and Hillingdon have the longest waits in London for dementia diagnosis. A partial answer was supplied that this may relate to a data entry problem, but we were promised a full answer later.
- A question about better provision of mental health services will also receive an extended answer later.
At month 6, the CCG is reporting break even at year to date and is forecasting to break even at year end on both its Programme and Running Cost budgets. Overperformance on acute contracts is £5m, as last month, achieved with the help of the 2014/15 transitional support of £5.5m and the marginal rate of 45% for over contract services – without those benefits the predicted end of year overspend on acute services would be £12.1m.There is year to date slippage of £1.495m against the Quality Innovation Productivity and Prevention plan (QIPP) but overall there is a £1k surplus on running costs for year to date.
In month 5 a number of targets were not achieved, but some were below target by only small amounts.Current assessments suggest that a deduction of £367k will be made from potential funding of £1.5m due to failure to meet London Ambulance Service performance targets. Hillingdon Hospital breached the 30 minute handover target for 164 patients and two handovers took over an hour. Other hospitals serving the CCG also missed these targets.
The LAS again missed the target of 75% of top priority calls arriving within 8 minutes, with 72.9% for Cat A Red 1 and 69.1% for Cat A Red 2.Hillingdon Urgent Care Centre:
Since opening in October 2013 the UCC has seen a steady increase in the numbers of attendances and discharges, with a seasonal decrese in August experienced across UCCs in North West London. Its contractual average of 188 patients per day was exceeded in every month in the first two quarters this year, with a high of 240 in June and a low of 202 in August. The UCC has sustained wait time of adults triaged within 20 minutes of arrival and children within 15 minutes, despite the increase in activity.Nurse recruitment remains a challenge but the service is reviewing innovative solutions to this national problem.
The UCC is undertaking patient surveys to understand why patients are accessing its services.Child and Adolescent Mental Health Services (CAMHs) Out of Hours Services:
The current out of Hour’s services to support young people with mental health problems is acknowledged as very limited. A pilot approach to implementation of agreed improvements is planned for 2015/16 funded by the 8 NW London CCGs.Key changes include moving from telephone access to Adult Mental Health Services to a help line to a CAMHs specialist, which eventually should operate a full out of hours service 5pm – 9am seven days a week.
Planned closure of maternity and related services at Ealing Hospital:
The date when the maternity, paediatrics and gynaecology units on the Ealing Hospital site will close is expected to be early in 2015. It was agreed that Ealing CCG should decide the closure date, depending on when alternative units are ready to receive its patients.
- Patient choice of access options eg via telephone, email or skype.
- Easier making of appointments – with more use of on-line services
- A named GP for each patient, with whom flexible length appointments can be made as appropriate up to four weeks ahead.
- Routine surgery opening hours 8am to 6.30pm Monday to Friday and 8am to 12 noon on Saturdays.
- Access to primary care 8am to 8pm every day in the local area for urgent unscheduled care
- Same day access to a GP for consultation on urgent conditions.
Primary Care Commissioning: In May 2014 NHS England invited Expressions of Interest in Primary Care Commissioning from Clinical Commissioning Groups with three levels of possible involvement. The NW London CCGs expressed an interest in the middle option, for joint commissioning by local CCGS and area teams, potentially supported by pooled funding arrangements. They have recently heard that their submission is sufficiently robust to progress to the next stage of development, which would establish shadow arrangements by November 2014 with an intention to go live on 1st April 2015. This will require the establishment of a Primary Care Co-commissioning “Committee in Common” between the commissioners. The CCGs will have to commit to these plans at their Board Meetings in public in October and November.2014, with parallel decisions by NHS England for London Region. The details remain flexible.
The Hillingdon System Resilience Group: This is the revised name of the group responsible for capacity planning and operational delivery across the local health and social care systems. It is chaired by Dr Mitch Garsin. NHS England published new guidance in June 2014 and awarded Hillingdon CCG £1.6m to maintain the 95% A&E four hour standard throughout the second half of 2014-15. The CCG has also been allocated £512.5k to improve referral to treatment times for elective care. In addition to locally funded schemes £4,975m resilience funding has been made available to the London Ambulance Service
Finance: At month 5, the CCG is reporting a break even position against plan at year to date and a similar expectation for year end. This is possible only with £5.5m transitional support received for acute services and payment on acute work above the agreed threshold at only 45% of tariff. Without those benefits a forecast of an overspend of £12.6m would have arisen for hospital services. Assuming delivery of the agreed plan an underlying deficit of £7m is now expected at year end. From 1st October work previously undertaken by the Commissioning Support Unit will be transferred back to the CCG.
Integrated performance: London Ambulance Service handovers at Hillingdon Hospital are significantly above both 30 minutes and 60 minutes targets; this may contribute to LAS also failing its target times for reaching emergency 999 patients. A number of other CCG targets were also not achieved, but most were close to target. Mental Health Early Intervention activity appears to be under-performing and difficulties are arising with respect to patients who are registered with out of Borough GPs.
Wheelchair service: The NW London CCGs currently work together on provision of wheelchairs, but CNWL has given notice that from 1st April 2015 it will be unable to undertake work on repair and maintenance of wheelchairs. New arrangements must now be developed. On wheelchair issues Hillingdon CCG is the lead commissioner for Harrow CCG.
Background to commissioning intentions for 2015-16: The number of patients attending A&E is increasing and more are being admitted. There has been less than expected use of ambulatory care pathways. More patients are being referred to hospital than expected and the Outpatient activity has not reduced as expected. Hillingdon has fewer diagnosed depression /anxiety patients compared to similar boroughs and attendances at A&E for Mental Health issues are increasing.Personal Health Budgets: From April 2014 people in receipt of NHS continuing health care funding have the right to a personal budget . This will be extended to anyone with a long-term condition who could benefit. Hilllingdon CCG has been working with Hillingdon Council to set up this option including fraud prevention, financial monitoring, access to the support of DASH (the Disability Association).
1. Finance: Overall at month 4 the CCG is reporting a £0.03 surplus year to date and is forecasting to break even at year end on both its Programme and Running Costs budgets.
However, an underlying deficit of £18.7m is expected at year end due to over-performance across its Acute providers portfolio and shortfall in its Quality, Innovation, Productivity and Performance (QIPP) plans.
2. Performance: The June Integrated performance Report noted that the CCG was meeting most constitutional performance measure with relatively few breaches. Actions to address shortfalls in performance were being addressed.
3. London Ambulance Service arrival to handover waits: In June 56 waits of over 30 minutes were reported at Northwick Park Hospital and 201 such waits at Hillingdon Hospital, with five at Northwick Park of over an hour and six over an hour waits at Hillingdon Hospital.
4. Perinatal Mental Health Disorders: These disorders affect an estimated 20% of women during pregnancy or up to a year postnatally. Up to 180 women a year in Hillingdon are likely to have a severe, disabling perinatal mental health disorder (psychosis, serious mental illness or severe depressive illness) and between 1000 and 2000 a less severe condition.
An initial review of local services suggests there are significant gaps, particularly in specialist care for women postnatally, and a Serious Incident Review following a postnatal suicide in 2012 found a number of areas where services need to be improved. An ongoing development programme is now underway to address these shortcomings.
5. NHS Continuing Healthcare: Brent, Harrow and Hillingdon CCGs work together in their responsibility to provide for the care of people who have been assessed as eligible for fully funded NHS Continuing Healthcare under the National Eligibility Criteria. Any challenge from families on the level of allocated funding is referred to the Health Ombudsman. Where possible the views of the patient and family will be taken into account but there is no way that patients or their families can “top up” the financial provision agreed by the CCGs.
However, an individual can appeal the commissioning decision in writing within 10 days through the Complaints and Governance Team.
NB Main points of interest from the meeting only:
Northwood and Pinner Community Hospital: A key element of the CCG’s Out of Hospital Strategy is the development of three “Hubs” to house a range of out of hospital services. It reviewed a range of potential sites including the Northwood and Pinner Hospital site. The CCG has now confirmed that it does not expect to use that site for any local health service developments in the future and it has written accordingly to NHS Property Service Ltd., which became responsible for the site on 1st April 2013.
Finance: The CCG is forecasting break even at year end based on an expected overspend of £14.3m for which transitional support will be available. An underlying deficit of £7m was forecast but that could rise to over £21m.
Performance: With a few exceptions the CCG is meeting performance targets but some of its providers failed particular targets. The London Ambulance Service had many breaches of the 30minutes from arrival to hand over target with seven over an hour breaches at Hillingdon Hospital and five at Northwick Park Hospital, plus failures to reach life threatened patients within target times.
Hayes Town Medical Centre: It was agreed that this Centre can close at the end of its current contract on 30th September as there are alternative facilities available.
Chronic Obstructive Pulmonary Disease: Development of COPD is slow and insidious, often not recognised by patients until lung function reduces to 50-60% of predicted value . Stopping smoking is most beneficial in the early stages of COPD. The condition is markedly under-diagnosed and there is much confusion between COPD and asthma. Within General Practice in Hillingdon there is much variation and up to 10-20% of spirometers used for review of COPD patients are not calibrated and maintained according to guidelines.
Hillingdon Urgent Care Centre: This UCC opened at Hillingdon Hospital on 1st October 2013. It is open 24 hours per day, 365 days per year. It is treating on average 238 patients per day, representing 61.7% of all patients to the site, without futher referral to the Emergency Department. Around 6% of the UCC patients are referred to the Emergency Department, 93% of them within the two hour target time. Late referrals usually occur when there is a surge of patients. The UCC is operating above contracted requirements. The next six months will focus on managing frequent attenders. Nurse recruitment remains a challenge, but this is a national problem.
Co-commissioning of Primary Care: In April 2013 NHS England assumed responsibility for commissioning primary care services including general practice, dental practice, pharmacy services and optometry services. Earlier this year NHS England invited interest from CCGs to participate in co-commissioning of general practice services. The 8 CCGs in NW London submitted a shared expression of interest on 20th June. Hillingdon CCG has made a commitment to explore this possibility rather than a commitment to undertake co-commissioning.
Move to Boundary House, Cricket Field Road, Uxbridge: This second floor accommodation will be the new HQ for Hillingdon CCG from the end of September 2014. There will be storage space in the basement and seven car parking spaces. Internal structural works are necessary before the move. The next key milestone is signing of the 5 year licence agreement.