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London’s Clinical Commissioning Groups and NHS England

(London region’s) response to the London Health Commission’s

report – ‘Better Health for London’

We would like to commend the London Health Commission’s recent report –

Better Health for London and the opportunity it presents to the NHS in London.

The report sets out the challenges that London currently faces and the

recommendations represent an excellent opportunity to bring fresh thinking on

how to bring about the improvements in health and care in the Capital that we all

aspire to achieve. Additionally, the ambitions and recommendations set out in the

report clearly place health, health inequalities and health and care at the centre

of debate for Londoners.

We are pleased that you have accepted the recommendation to convene and

personally chair a group to prepare a unified delivery plan and oversee

implementation of the Commission’s recommendations and make the

recommendations for London a reality.

We broadly support the recommendations detailed within Better Health for

London which highlight the need for the different agencies responsible for health

and care in the capital to each play their part, and in some cases work together

to achieve the ambitions. Importantly, the recommendations demonstrate the

need for the NHS and others to better involve London’s different communities in

the delivery of the solutions in order to truly make London the healthiest global

city.

Working with our partners, we would like to offer our commitment to supporting

making implementation of the recommendations a reality for Londoners.

This response to the recommendations outlined in Better Health for London has

been jointly developed by London’s Clinical Commissioning Groups and NHS

England (London Region). We have considered the recommendations and

recognise the importance of our relationship – and the relationships with our

partners – and it is through the collective effort that we will strive to deliver much

of what is recommended in Better Health for London in order to truly transform

health and care for Londoners.

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We have concentrated our response on:

Who we are;

Our partners;

The Five Year Forward View;

Taking the recommendations of Better Health for London forward;

Our transformation priorities; and

The proposed vehicle to take forward the recommendations pertaining to

the NHS in London.

We trust this response is helpful and we look forward to working with you to

make the ambitions set out in Better Health for London a reality for Londoners.

Whilst we are facing unprecedented challenges, we ask for your support in

accepting the recommendations of Better Health for London as detailed in our

enclosed response. We are confident that this will be an important foundation to

truly make London the healthiest global city.

1. Who we are: London’s Clinical Commissioning Groups

1.1 There are 32 Clinical Commissioning Groups (CCGs) in London. Each

CCG is a statutory NHS body with its own governance arrangements;

these vary according to its Constitution. CCGs are membership

organisations of the GP practices within their boundaries. They are

responsible for meeting the health needs of their populations and their

main focus is on local issues.

1.2 Clinical Commissioning Groups operate by commissioning healthcare

services including:

Elective hospital care;

Rehabilitation care;

Urgent and emergency care;

Maternity services;

Most community health services; and

Mental health and learning disability services.

1.3 Clinical Commissioning Groups work with patients and healthcare

professionals and in partnership with local communities and local

authorities, including though Health and Wellbeing Boards. These

partnerships improve the commissioning and delivery of services across

NHS and local government, leading in turn to improved health and

wellbeing for local people.

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1.4 London’s CCGs also work together in different geographies where it

makes sense to do so, where value can be added across a larger

population.

1.5 The 32 London CCGs work together to discharge their responsibilities and

ensure that robust arrangements are in place to enable effective

collaboration. These arrangements reflect the membership nature of

CCGs.

1.6 The principal objectives for CCG collective working in London are:

To manage collective commissioning arrangements.

To liaise with other London wide organisations such as the NHS

England (London), Mayor’s office and London Councils.

To work in partnership with the NHS England (London) to plan, and

to manage strategic change which cross CCG boundaries.

To promote shared learning to improve performance.

To co-ordinate other activities as required.

2. Who we are: NHS England (London Region)

2.1 While operating within a single organisational structure, NHS England’s

Operations and Delivery Directorate has four regional teams of which

London is one, co-terminous with the Greater London Authority (GLA).

London Region has Area Teams for South; North West; and North Central

and East London. This enables the development of local relationships and

local knowledge essential to effective and efficient working.

2.2 NHS England (London Region) has oversight and leadership for the NHS

in London and commissions more than £15bn of services for the 8.17

million people living in the capital. These include general practitioners

(GPs) and over 140 specialised services such as:

Forensic mental health;

HIV treatment;

Treatment for children with congenital heart conditions;

Cystic fibrosis treatment;

Complex spinal surgery; and

Healthcare for those in the criminal justice system.

2.3 The London Regional Team has directorates aligned to the national

support team: Medical; Nursing; Operations and Delivery; Finance;

Patients and Information; Communications; and Human Resources and

Organisational Development. Unique to the London Regional Team is a

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Transformation Directorate, established in recognition of the unique

challenges facing the NHS in the Capital. In light of the publication of

Better Health for London and the establishment of the London

Commissioning System Design Group there is the shared recognition that

transformation in London needs to be jointly owned with London’s CCGs.

2.4 London’s CCGs and NHS England (London Region) is focused on

improvements against the NHS Outcomes Framework1 and ensuring

citizens receive their rights as set out under the NHS Constitution2.

Putting Patients First: the NHS Business Plan 2013/14 – 2015/16 (will be

annexed) sets out how we are responding to our Mandate. Everyone

Counts: Planning for 2014/15 to 2018/19 (will be annexed) sets out how

we propose that the NHS budget is invested so as to drive continuous

improvement and to make high quality care for all, now and for future

generations into a reality.

2.5 The recently published Five Year Forward View (will be annexed) for the

NHS in England calls for decisive action over the next five years to ensure

that the health and care quality gap does not widen. London’s CCGs and

NHS England (London Region) support this bold vision and recognise the

alignment between the Five Year Forward View and the recommendations

detailed in Better Health for London, and the benefits that implementation

of these recommendations will bring.

3. Our partners

3.1 London’s CCGs and NHS England (London Region) work closely with the

London regional offices of our national partner organisations:

NHS Trust Development Authority (TDA);

Public Health England (PHE;

Health Education England and Local Education and Training Boards

(LETBs);

Commissioning Support Units (CSUs);

Healthwatch England and local; and

Monitor.

3.2 We also closely consider the priorities and guidance of other national

bodies, such as the National Information Board, a recent report from

which (Personalised Health and Care 2020: Using Data and Technology

to Transform Outcomes for Patients and Citizens) will set direction for our

work in this area.

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3.3 In London, we continue to develop relationships with other organisations,

representatives and partners, including:

Patients and service users;

The Mayor and the Greater London Assembly;

London Clinical Senate;

Primary care providers;

16 acute NHS trusts;

Three mental health NHS trusts;

Two community trusts;

18 Foundation Trusts;

The London Ambulance Service;

Three Academic Health Science Centres and Networks;

London Health Board;

London-wide LMCs;

London Councils;

33 local authorities;

Health and Wellbeing Boards; and

Voluntary services and charities.

3.4 Most importantly we strive to work with, and for, Londoners and the people

visiting and working in our great city.

3.5 The opportunities of our clinically-led health commissioning system are

clear in that we are able to respond to local need, supported at scale

where this adds value. However, the challenges of multiple interests and

involvement across a citizen’s pathway of health – from prevention and

care in the home to highly specialised intervention and rehabilitation – are

complex and require very effective partnership working across multiple

organisational boundaries.

3.6 We would like to take this opportunity to outline our ongoing commitment

to working with our partners to take forward implementation of the

recommendations of Better Health for London.

4. NHS England’s Five Year Forward View

4.1 NHS England’s recently published Five Year Forward View sets out why

the NHS needs to change, the actions we will need to take to deliver

transformed care for patients, and the help we need from others. It calls

for action on four fronts.

4.2 Firstly, it argues that the NHS needs to do more to tackle the root causes

of ill health. The future health of millions of children, the sustainability of

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the NHS and the economic prosperity of Britain all now depend on a

radical upgrade in prevention and public health. The Five Year Forward

View backs hard-hitting action on obesity, alcohol and other major health

risks.

4.3 Secondly, it commits to giving patients more control of their own care,

including the option of combining health and social care, and new support

for carers and volunteers.

4.4 Thirdly, it says the NHS must change to meet the needs of a population

that lives longer, for the millions of people with long-term conditions, and

for all patients who want person centred care. This means breaking down

the boundaries between family doctors and hospitals, between physical

and mental health and between health and social care. The Five-Year

Forward View sets out new models of care built around the needs of

patients rather than historical or professional divides.

4.5 Fourthly, it sets out the actions we will need to take in order to develop

and deliver the new models of care, including greater alignment between

the national NHS bodies to provide meaningful local flexibility in the way

that payment, rules and regulatory requirements are applied. It proposes

more investment in our workforce, technology and innovation.

4.6 It concludes that although a better future is in view for the NHS, action will

be needed on three fronts - demand, efficiency and funding. More action

on any one of the three will reduce the pressures on the other two. The

Five Year Forward View shows how delivering on the transformational

changes set out, combined with staged funding increases as the economy

allows could feasibly close the £30 billion gap by 2020/21, and secure a

far better health service for England.

4.7 As commissioners of NHS care in London, we welcome the

recommendations set out in the London Health Commission’s report

Better Health for London which outline important changes that need to

happen to ensure that London is the healthiest global city. It is important

to highlight the broad alignment between the Five Year Forward View and

the London Health Commission’s Better Health for London, the latter of

which sets out ambitions for the Capital and tangible recommendations

that would in part enable a robust response to the challenges highlighted

in the Five Year Forward View.

4.8 In London, Strategic Planning Groups of CCGs and Area Teams –

working with stakeholders and communities – have developed five year

strategic plans to achieve the ambitions set out in our planning guidance.

The five year plans also highlight alignment between the action called for

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in the Five Year Forward View and the recommendations detailed in

Better Health for London.

4.9 We therefore call for you, as Mayor of London and commissioner of the

London Health Commission inquiry, to accept the recommendations

outlined in Better Health for London in order for London’s CCGs and NHS

England (London Region) to take them forward through to implementation,

to enable the Capital to respond to the challenges and deliver the

transformed care for patients identified in Five Year Forward View. We

also call on you in your role as chair of the group that will prepare a unified

delivery plan and oversee implementation of the Commission’s

recommendations to ensure that other agencies responsible for

recommendations do so in order to unlock some significant issues in

London.

4.10 Recognising the challenge ahead, a joint working group between London’s

CCGs and NHS England was established in August 2014 to work through

the implications of implementing the recommendations set out in Better

Health for London through the redesign of commissioning of health

services. The London Commissioning System Design Group has

developed this joint response from London’s CCGs and NHS England

(London Region) to the recommendations in Better Health for London

jointly made to us as commissioners.

4.11 In developing the response, the London Commissioning System Design

Group has been working through the recommendations of Better Health

for London in the context of all the other changes in the NHS, to produce a

coherent plan for taking action forward. This will enable us as

commissioners of health services in London to play a full part in delivering

the vision of Better Health for London.

5. Better health for all

5.1 The Five Year Forward View argues that the NHS needs to do more to

tackle the root causes of ill health. The future health of millions of children,

the sustainability of the NHS and the economic prosperity of Britain all

now depend on a radical upgrade in prevention and public health. The

Five Year Forward View backs hard-hitting action on prevention including

obesity, smoking, alcohol and other major health risks.

5.2 We welcome the Better Health for London recommendations to enable

better health for all of London’s population and to firm take action on

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tackling the root causes of ill health, in order to meet the challenges set

out in the Five Year Forward View.

5.3 We support the approach of Better Health for London: starting from a

simple premise: that a truly great global city is a healthy city. We support

the report’s aspiration to be the world’s healthiest major global city

through:

Reducing smoking rates in the Capital;

Addressing London’s obesity emergency;

Helping Londoners – especially children – to make better and

easier, healthier food and drink choices;

Encouraging work place health initiatives;

Reducing excessive drinking;

Promoting active travel; and

Addressing poor air quality.

5.4 We recognise that tackling these issues will be essential to ensure the

sustainability of the NHS and that preventing ill-health must be a core

focus of the health and care system. Whilst these recommendations are

not made to the NHS in London we recognise that the NHS needs to do

more to tackle the root causes of ill health. In order for truly effective

intervention to take place, we are committed to partnering with Public

Health England and local authorities to support them in leading the way in

delivering preventative initiatives and taking these recommendations

forward Importantly, we will maintain a commitment to continue to engage

with local authorities and Health and Wellbeing Boards to support the

development of Joint Strategic Needs Assessments to support these

important issues.

5.5 NHS England (London Region) also acknowledges its public health role

and is committed to working to improving immunisation rates to positively

impact on health and reduce health inequalities. This is as well as

supporting our partners to take forward the recommendations in Better

Health for London.

5.6 Additionally, the Five Year Forward View calls for a mental health first

aider in every NHS organisation and active travel. Better Health for

London echoes these calls and London CCGs and NHS England (London

Region) are committed to working with Public Health England, the GLA

and local authorities to jointly take this recommendation forward.

5.7 Furthermore, the recent report from Public Health England – From

evidence to action: opportunities to protect and improve the nation’s health

highlighted seven priority focus areas – four of which align to priority areas

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of Better Health for London (the other three being dementia, tuberculosis

and antimicrobial resistance).

6. Better Health for London’s children

6.1 We welcome Better Health for London recommendations for children and

voice our broad support for the public health recommendations within this

section and ensuring that London’s children are a clear priority through:

Supporting London’s most vulnerable families;

Addressing London’s childhood obesity emergency – helping

Londoners – especially children – to make better and easier,

healthier food and drink choices;

School-based interventions for physical and mental health; and

Reducing the variation in the quality of physical and mental

healthcare.

6.2 Outlined in the Five Year Forward View is that the future health of millions

of children is dependent on the radical upgrade of public health, which

mirrors the challenge London faces with the number of primary school

children who are obese. We know, and are deeply ashamed that London

has the highest rate of childhood obesity of any major global city.

6.3 Whilst the Five Year Forward View does not draw on children with a

particular focus or specific issue, we welcome Better Health for London’s

focus and identification that London's children are getting a particularly

raw deal – children of vulnerable families do not always get the support

they need; healthy food and drink choices are not always the easiest

option; healthcare remains fragmented; there is variation in the quality of

care provided; and hospital mortality rates are higher than anywhere else

in the country. This is therefore why it is so important that we give

London’s children a better deal to ensure the very best start in life for them

that we can.

6.4 Similar to previous section which largely focuses on the public health

agenda, we recognise that tackling these issues will be essential to ensure

the sustainability of the NHS and we will support our partners such as

Public Health England, local authorities and those in the education sector

to take these recommendations forward. We particularly express our

support for the recommendation for closer links between education and

health; these links are well evidenced to improve outcomes for children.

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6.5 We outline our broad support for the recommendation to address and

eliminate the variation in quality of care and outcomes for London’s

children and young people. We echo Better Health for London’s call to

improve the health outcomes of London’s children and young people

through the development and implementation of a number of integrated

care systems – spanning physical and mental health and care across all

settings – that ensure the delivery of agreed standards. The need to

develop integrated systems of care has also been highlighted as an area

of focus by London’s Strategic Clinical Network for Children and Young

People.

6.6 Additionally, reducing the fragmentation of services for children and young

people and ensuring clinical dependencies between services are met are

integral to the development of integrated systems of care.

6.7 The London Commissioning System Design Group has agreed children

and young people as one of the clinical priority programmes that will be

taken forward as transformation programme with the aim of reducing the

variation in service provision and patient outcomes. This will build on the

maxim set out in Better Health for London: to start with London’s children

and young people, not London’s NHS. The exact scope of this programme

and timeframes for delivery are currently being jointly developed between

commissioners.

7. Better care

Personalised care

7.1 NHS England’s Five Year Forward View calls for the NHS to take decisive

steps to break down the barriers in how care is provided between family

doctors and hospitals, between physical and mental health, between

health and social care. It outlines that the future will see far more care

delivered locally but with some services in specialist centres, organised to

support people with multiple health conditions, not just single diseases.

7.2 We wholeheartedly agree with Better Health for London’s belief that care

should be more personal, planned around groups of people with broadly

similar needs, rather than around groups of professionals with broadly

similar skills. Rather than care provided around primary versus secondary,

or mental versus physical, a system that holistically considers all aspects

of care for a particular individual.

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7.3 We recognise the importance of the need to understand the different

needs of different groups as the foundation of the new approach proposed

by Better Health for London and this is welcomed. We fully support a

system in which care is provided for groups of similar individuals, in which

people are treated as people, unique and complex, not as an ailment,

condition, or piece of anatomy. This will be a system that will ensure better

care delivery by removing the complexity of the system from the patient

experience and improve patient outcomes.

7.4 We support in principle for the maxim set out in Better Health for London:

start with Londoners, not London’s NHS. Start with people and how best

to meet their needs, their wants, and their expectations – not those of the

system.

7.5 Whilst the approach to looking at the needs, wants and expectations of

different population groupings is supported by London’s CCGs and NHS

England (London Region), local health economies will seek to understand

their own population and develop their own model.

7.6 Providing care that is more personal, planned around groups of people

with broadly similar needs, is a significant shift from care being provided

around institutions – rather than care provided around primary versus

secondary, or mental versus physical, a system that holistically considers

all aspects of care for a particular individual.

7.7 Practically, we understand that this will mean commissioning and

providing more joint teams in the community, more joined up working, and

more integration between health and social care. We strongly support

taking this recommendation forward.

7.8 In conjunction with this, we would like to set out our broad support for

ensuring people who use services are treated as partners in the design

and implementation of improvements to care. Taking the

recommendations forward through transformation programmes to drive

implementation would have the public voice at the heart of developments.

7.9 We also support the indication that the provider system will need to

change and adapt to reflect this new approach. This will also enable the

NHS in London to respond to the expectations set out in the Five Year

Forward View which recognises that a one size fits all approach is no

longer appropriate, and sets out a number of viable models of care for

local health and care services to consider.

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Care for marginalised groups

7.10 We are delighted to see such a strong focus on mental health in the Better

Health for London report. As you are aware with the recent publication of

your own report London Mental Health: the invisible cost of mental ill

health3, mental ill-health alone costs London £5.5 billion a year in lost

working days, and £2.5 billion a year in health and social care costs. More

than a million Londoners will experience mental ill health this year; more

than 100,000 of them will be children. Mental health is all around us.

7.11 We know that too often, physical and mental health are unnecessarily

separated which can result in alarming consequences for patients – the

life expectancy of a man who has experienced psychosis is 14 years less

than the average. We believe that working towards Better Health for

London’s ambition to reduce the gap in life expectancy between adults

with severe and enduring mental illness and the rest of the population by

10% will help us achieve call for ‘parity of esteem’ as set out in the Five

Year Forward View.

7.12 Building on this we would like to outline our broad support for the

recommendations set out in Better Health for London on strengthening the

role of mental health in primary care and timely access to Increasing

Access to Psychological Therapies (IAPT) and early intervention. This

would enable London to strive towards making improvements to care and

services set out in the Five Year Forward View, which are desperately

needed over the next five years. These include the introduction of access

targets to improve earlier diagnosis and treatment as well as better

integrated care for patients with both mental and physical healthcare

needs.

7.13 We also broadly support the recommendation for better care for mental

health patients in crisis. London’s Mental Health Strategic Clinical Network

has recently published mental health standards for patients in crisis and

we would look to build on these through the development of a multi-

agency model of care for this group.

7.14 Furthermore, we welcome the recommendation to design a digital mental

health support system to ensure consistency across all of London and

developing local enhancements if necessary.

7.15 The London Commissioning System Design Group has agreed mental

health as one of the clinical priority programmes that will be taken forward

as a transformation programme to support the development of a multi-

agency model of care for patients in crisis, standards for strengthened

mental health in primary care including access to psychological therapies,

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ensuring the delivery of access targets for the treatment of psychosis and

the design of a digital mental health support system. The exact scope of

this programme and timeframes for delivery are currently being jointly

developed between commissioners.

7.16 A significant amount of work is already underway across London to

improve services and outcomes for homeless people and rough sleepers.

However, this group of people are transitory, and so the issue is

necessarily London-wide and more needs to be done to link programmes

across London with each other and mainstream services. We therefore

welcome the recommendation to develop a multi-agency approach to

healthcare for the homeless population and extend our commitment to

working with our agency partners on developing dedicated care teams and

identifying a lead commissioner of these services.

7.17 The London Commissioning System Design Group are considering the

scope of pan-London support to develop a multi-agency approach to

healthcare for the homeless population to take forward next year.

7.18 Furthermore, NHS England (London Region) maintains its commitment to

improving services for other marginalised groups such as veterans,

offenders, those in immigration detention centres and those in asylum

hostels.

Primary care

7.19 We recognise that the recommendations set out the section for ‘Better

care for all’ will have the greatest impact on primary care, more so on

general practice. The Five Year Forward View outlines that the foundation

of NHS care will remain list-based primary care. However, given the

pressures they are under, we welcome the notion from both the Five Year

Forward View and Better Health for London that a ‘new deal’ for GPs is

needed.

7.20 The Five Year Forward View calls for the NHS to invest more over the

next five years in primary care, while stabilising core funding for general

practice nationally over the next two years. It outlines that CCGs will have

the option of more control over the wider NHS budget, enabling a shift in

investment from acute to primary and community services. Additionally,

the number of GPs in training needs to be increased as fast as possible,

with new options to encourage retention.

7.21 We welcome Better Health for London’s focus on and call for modern

general practice and the recognition that investment in general practice is

required. It is recognised that modern, accessible, purpose-built or

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purpose-designed facilities will cost more to run and so along with the

capital investment, we welcome the call for a commitment to increase the

proportion of total NHS expenditure dedicated to primary medical care

rising for each of the next five years.

7.22 We also outline our support for the recommendations for reform in Better

Health for London that come with the call for investment. We support

reform to end professional isolation and agree with supporting GPs to

work in networks, with the aim that every GP practice has the opportunity

to join and participate in a network of local practices, as well as supporting

those that are already doing so, for example in north east London. It is

important to highlight that patients being able to move freely between

networks will improve access to range of services.

7.23 We welcome the recommendation to allow existing as well as new

providers to set up new GP services in areas of poor provision. We know

that access to general practice is variable across the capital and that 60

per cent of practices in London are rated worse for access by patients

than the England average4, and we therefore agree with the need to

increase access for Londoners. We will learn from previous efforts in this

area in developing criteria for the implementation of this recommendation.

7.24 We offer our broad support for the recommendation around ambitious new

service and quality standards to be set and more tightly enforced. The

Strategic Commissioning Framework that has already been developed by

CCGs and NHS England (London Region) is the first step in responding to

this recommendation.

7.25 The Strategic Commissioning Framework for Primary Care Transformation

in London describes a new vision for general practice in London. The

Framework aims to support local planning to provide more accessible,

proactive and co-ordinated care for all of London, so that Londoners have

access to primary care that meets their needs, wants and expectations;

and also outlines some of the considerations for delivering this vision – for

example that investment, change in the ways of working and workforce,

and provider development are all needed.

7.26 It is expected that the draft Framework will proceed to an engagement

phase from December 2014 to March 2015, where London’s CCGs and

NHS England (London Region) will engage with clinicians and the public

to further develop, and understand implications of the Framework. Full

implementation of the Strategic Commissioning Framework will enable

greater access to general practice for Londoners and a higher quality of

care.

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7.27 The London Clinical Commissioning System Design Group has agreed

that the work on primary care should continue and the Group has agreed

this as an enabling priority transformation programme, building on the

Strategic Commissioning Framework for Primary Care Transformation and

to further support the development of modern general practice. The full

scope of this and timeframe for delivery is currently being considered

between commissioners.

Specialist care

7.28 The Five Year Forward View calls for more integration across care – both

horizontally and vertically. Across the NHS, urgent and emergency care

services will be redesigned to integrate between emergency departments,

GP out-of-hours services, urgent care centres, NHS 111, and ambulance

services.

7.29 Better Health for London recognises that more needs to be done to

reduce the variation in outcomes experienced by Londoners admitted to

hospitals for emergency care and meet the ambition set out to close the

gap between weekday and weekend mortality rates. Whilst we would

agree with meeting this ambition, both London’s CCGs and NHS England

(London Region) recognise that the wider system of urgent and

emergency care requires transformation in order to provide access to the

highest quality of care. We would like to widen the ambition and take this

transformation forward by continuing with our existing programme of work.

7.30 The London Commissioning System Design Group has agreed that

transforming urgent and emergency care in London should be taken

forward as one of the clinical priority programmes that requires a large

scale transformation programme to improve outcomes through the

establishment of urgent and emergency care networks that provide access

to the highest quality of care and support the ongoing implementation of

the London quality standards for acute emergency services. The scope of

this programme will build on the maxim set out in Better Health for

London: to start with Londoners, not London’s NHS consider the different

needs, wants and expectations of London’s population groups that use

urgent and emergency care services. The timeframes for delivery are

currently being considered between commissioners.

7.31 The Five Year Forward View highlights that the future will see far more

care delivered locally but with some services delivered in specialist

centres. Better Health for London also calls for some services to be

provided at scale, in centres of excellence which have the very best

equipment and expertise.

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7.32 Better Health for London recognises that whilst progress has been made

with developing centres of excellence in London, based on life-saving

principles, there remains much more to do in specialist areas like

cardiovascular, cancer, and elective orthopaedic services in particular.

7.33 More widely, Better Health for London urges that the momentum created

by life-saving initiatives for specialist care like Healthcare for London

should be given new impetus. Other parts of the specialist care system

that could benefit from the same approach should be actively directed

towards reform, and those programmes which are already under way

should be accelerated.

7.34 We are committed to working with our partners in the Integrated Cancer

Systems to drive forward the implementation of the Five Year Cancer

Commissioning Strategy for London. Part of this will be to support the

acceleration of plans develop sustainable centres of excellence for rarer

cancer care in order to reduce variation and improve outcomes and

patient experience.

7.35 NHS England is responsible for the commissioning of three national

cancer screening programmes and so just as importantly, we maintain our

commitment to working with the Integrated Cancer Systems to improve

early detection and awareness of cancer. Furthermore, we are committed

to working with our partners to improve the lives of those living with and

beyond cancer.

7.36 Cancer has been agreed as a clinical priority programme by the London

Commissioning System Design Group to be taken forward as a

transformation programme to support the development of centres of

excellence for rarer cancer and the delivery of the Five Year Cancer

Commissioning Strategy for London which sets out a compelling case for

accelerating the pace of transforming cancer services so that every

Londoner receives a world class experience from prevention, through

early detection to treatment, subsequent support and for end of life care.

The exact scope and timeframes for delivery are currently being

considered between commissioners.

7.37 Some consolidation of cardiovascular services has taken place and we

welcome the recommendation to accelerate plans further. Consolidating

the existing providers of cardiovascular procedures into specialised

centres of excellence would cement these improvements further.

7.38 Additionally, we know that patient outcomes for patients undergoing

elective orthopaedic procedures currently vary depending on where

Londoners live and are treated. Huge variations are seen across waiting

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times, infection rates and lengths of stay. We therefore support in principle

the recommendation to review this service area and ascertain the level of

change that may be needed.

8. Maximising science, discovery and innovation to enhance

economic growth

8.1 The Five Year Forward View calls for the NHS to become one of the best

places in the world to test innovations that require staff, technology and

funding all to align in a health system, with universal coverage serving a

large and diverse population. In practice, our track record has been

decidedly mixed, and we have lagged behind other industries in our use of

digital technology to improve experience and outcomes. The Five Year

Forward View highlights that too often single elements have been ‘piloted’

without other needed components. Aligning the work of the Academic

Health Science Networks, NHS Improving Quality and the NHS

Leadership Academy is highlighted as supporting this.

8.2 We offer broad support for the Better Health for London recommendations

to maximise science, discovery and innovation to enhance economic

growth, and for London to be a test site or ‘incubator’ for the development

of innovative practices. In doing so we support the three Academic Health

Science Networks in London to forge greater links with commissioners to

ensure priorities are aligned and supported.

8.3 We support the process of engaging London’s Academic Health Science

Centres and Networks – recognising the dialogues and collaborative

working that has taking place during the London Health Commission.

8.4 Better Health for London highlights the need to build upon our Capital’s

assets such as our thriving research and development in the life science

sector, valuable datasets, global corporations, top class talent and of

course our large and diverse population.

8.5 We echo the call from the Five Year Forward View in recognising the

expanded role of the Academic Health Science Networks in supporting

innovation, not just in technology but in supporting broader care delivery

and prevention too.

8.6 The focus areas identified for further investment and research (digital

health and dementia) are welcomed and supported by London’s CCGs

and NHS England (London Region). Digital health is a particular focus of

the Five Year Forward View and investment in this area in new

approaches within London – including app development and the use of

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other digital technologies – will enable greater self-care and self-

management. We are committed to developing partnerships with the

voluntary sector and industry to support digital inclusion.

8.7 We also welcome the recommendations for London to trial new

approaches to patient reported outcomes and personally controlled

budgets. These recommendations align to the National Information

Board’s framework for action, Personalised Health and Care 2020: Using

Data and Technology to Transform Outcomes for Patients and Citizens.

The framework describes how data and technology should be used to

increase personalisation and improve patient experience and quality of

care through information sharing, improved processes, and greater

efficiency and transparency. The framework references the opportunities

afforded by Better Health for London in providing the conditions to enable

innovation and better access to innovative treatments through the

enhanced use of technology and information sharing between and across

institutions.

8.8 We support data sharing and streamlining of trials. We were pleased to

read that the National Institute for Health Research and the Medical

Research Council have invested to improve recruitment for clinical trials,

improving London’s attractiveness as a place for research. We hope that

our support for data sharing and streamlining of trials will ensure that the

pace of adoption and innovation increases.

8.9 Whilst recognising that industry will be key partners in delivering these

recommendations, it is important to highlight that these are all areas

where London has a key competitive advantage which can therefore

support our Capital city to lead the way – this has the potential to benefit

the whole country.

9. Making it happen

9.1 Better Health for London sets a bold agenda for improving health and care

in London. Implementation of the recommendations relies on our

commitment as commissioners of healthcare in London, as well as our

partner organisations such as Public Health England, local authorities, and

the Greater London Authority to take things forward. As such, we welcome

the focus on the critical enablers to make many of the recommendations

to improve outcomes a reality, specifically changes to:

The way NHS information is handled in London;

How the NHS pays for services in London;

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The NHS estate in London; and

The NHS workforce in London.

9.2 We are broadly supportive of these recommendations. We acknowledge

that changes in reform for each of these critical enablers also echoes the

calls made nationally in the Five Year Forward View for example changes

to regulatory, pricing and funding levers, support for a modern workforce,

exploiting the information revolution and driving efficiency and productive

investment.

Information

9.3 The Five Year Forward View calls for exploitation of the information

revolution and as health and care commissioners we welcome and we will

embrace Better Health for London’s call for advanced data analytics to

better understand care needs and to commission higher quality care.

Again, these priorities are aligned to the National Information Board’s

framework for action, Personalised Health and Care 2020: Using Data and

Technology to Transform Outcomes for Patients and Citizens.

9.4 We welcome the emphasis in Better Health for London on the

personalisation of health and care by supporting the increased sharing

of data through technology for patients, citizens and those that care for

them. London CCGs and NHS England (London Region) are also uniquely

placed to work in collaboration with AHSNs, Local Authorities, the Health

and Social Care Information Centre (HSCIC) and other partners in driving

forward solutions in real-time information exchange – the ‘electronic glue’

that the Five Year Forward View refers to that will enable systems to talk

to one another for the benefit of direct patient care, commissioning and

research.

Funding and allocation

9.5 We agree in principle with Better Health for London’s recommendation to

promote greater equity in financing. Whilst the principle is understood it is

important to highlight that there are different ways to deliver

transformational change. There is an important role for London’s leaders

to ensure that the national allocation formula fairly takes account of and

reflects the real needs of Londoners and the characteristics of inner and

outer city areas.

9.6 As commissioners we support the principle that there needs to be greater

equity in financing the health and care system to effect the

transformational change required in London, we would add to this that

managing transition and having appropriate governance in place is also an

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important principle. There are however different ways of ensuring this

greater equity in financing and along with NHS England (London Region),

London’s CCGs and Strategic Planning Groups should consider

developing local initiatives to promote financial stability, learning from

examples elsewhere.

9.1 London’s CCGs and NHS England (London Region) recognise that there

is a need to invest in transformation at all levels and we offer general

support for the establishment of a transformation fund. We support that

scale is needed to deliver some of the recommendations and some

propositions will be better delivered together where added value is

demonstrated. Some areas of London have already invested in a

Transformation Fund for example, north west London. As the scope of the

transformation work needed in London is further defined in the coming

months, the level of investment in the transformation fund will be agreed.

Estates

9.2 We very strongly support the recommendations for estate and capital and

we would like to note that implementation of these recommendations are

critical to delivering real strategic change. We are enthusiastic at the

prospect of London being a test bed for driving important changes that are

needed not only in the Capital, but across the country.

9.3 Implementation of these recommendations will require new partnerships

and different ways of working which we are committed to. We would also

urge support from our partners for example the Department of Health,

NHS Property Services, Community Health Partnerships, Monitor and the

Trust Development Authority and are pleased to highlight that discussions

to build this support are already underway.

9.4 We would like to highlight our commitment to work with our local authority

partners, NHS Property Services and Community Health Partnerships in

the development of Strategic Planning and Capital Boards to ensure that

estates planning becomes a core element of strategic commissioning and

planning.

9.5 Estates issues are a significant constraint on the development of primary

care. Much primary care estate comprises small residential style

properties not fit for to provide modern primary care and community

services. However, the NHS is unable to improve this estate due to the

ownership model, where most primary care estate is not owned by the

NHS but by practice GPs, self-employed contractors, with their property

their principle asset.

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9.6 We welcome the recommendation to bring changes to rent reimbursement

for general practice, and highlight that for this recommendation to be

implemented, it will require genuine alternative premises offered with the

appropriate revenue implications fully factored in. There is considerable

evidence that the value of the surplus and underused NHS estate in

primary, community and acute settings could help to meet this cost.

9.7 The London Commissioning System Design Group has agreed that

estates will be a priority enabling programme to support transformation in

other areas, for example primary care, as well as supporting the reform of

acute hospital estate and strategic estates planning. The exact scope and

timeframe for delivery of this programme is currently being considered

between commissioners.

Workforce

9.8 There is no doubt that health and care services must change to meet the

needs of our population within the financial constraints which we operate.

The workforce needs to be ready to deliver within new delivery models

which will often require new training and education.

9.9 To achieve the level of transformation of service delivery and clinical

behaviour envisaged in the recommendations set out in Better Health for

London will require significant investment in the development of the

current and future workforce. This requires a level of proactive partnership

working by London’s commissioning community (NHS England (London

Region), CCGs and local authorities), Health Education England and the

provider leadership community to enable the continuation of the journey

we are on to achieve this.

9.10 We extend our support to our partners in Health Education England to

deliver the recommendations to support a modern workforce. The call for

this is outlined in both Better Health for London and the Five Year Forward

View. A modern workforce will enable the delivery of more personalised

care – which as commissioners of health care in London – we all strive to

achieve.

9.11 Not only do we extend our support to Health Education England to deliver

the recommendations to support a modern workforce but we also commit

to working proactively with them to ensure that the levers for change that

we control are aligned to support the pace of change that will be

necessary.

9.12 In addition, we support our partners at the Trust Development Authority

and Monitor to work with the Greater London Authority to encourage the

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transfer of unused NHS buildings for redevelopment and disposal and

hope that this will support affordable housing for our NHS workforce.

10. Leadership

10.1 We wholeheartedly agree with the Commission’s ambition for London to

be the healthiest major global city, and we also recognise that this will take

significant leadership from the Mayor, from local councillors and their

officers, from the NHS and from many other parts of London’s institutions

and society.

10.2 Whilst we note that the recommendation for you as the Mayor to appoint a

London Health Commissioner – a champion for health to lead the better

health agenda between local government, public health and the NHS – is

not one for the NHS in London to lead the implementation of, we wanted

to bring to your attention our thoughts on this recommendation.

10.3 We welcome a role which is facilitative in championing health, and

engaging other GLA departments in health, rather than a scrutiny role.

This would be beneficial in putting London’s case forward nationally,

ensuring we are funded appropriately.

10.4 It is important to highlight that we believe that creating a further level of

bureaucracy should be avoided. Additionally, there would need to be

agreed funding for the post to be successful rather than this being funded

from NHS budgets.

10.5 We agree that one of the greatest strengths and uniqueness of the

London Health Commission has been the joint working between local

government and the NHS to build a strong coalition for change. Moving

forward, we recognise that there is a need to build on this to strengthen

strategic leadership for health in the Capital by closer collaboration. We

are committed to working together with Public Health England to meet this

leadership challenge.

10.6 We broadly support the recommendation for NHS England to further

empower CCGs to work together in different ways – with their local

authority partners – to improve the care across multiple boroughs.

10.7 Whilst the recommendation to devolve further decision-making powers to

Strategic Planning Groups is broadly supported, Strategic Planning

Groups should be able to organise themselves in different ways providing

that their organisation will enable them to function effectively. We highlight

that a ‘one size fits all’ approach is unsuitable.

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10.8 Currently Strategic Planning Groups are responsible for creating five year

strategic plans, and some also play a leading role in major acute service

reconfiguration and developing out of hospital strategies. In addition,

Strategic Planning Groups may play an increasing role in primary care

commissioning, specialist commissioning and the development of

Strategic Planning and Capital Boards.

10.9 The London Commissioning System Design Group is currently working to

consider the relationship between NHS England (London Region) and

Strategic Planning Groups and outline the most effective ways of working

together going forward. In doing this, it may be that Strategic Planning

Groups will have to revisit their current governance structures.

Transparency in this process is supported and we highlight that any

Strategic Planning Group arrangements should be as equally as

transparent as those of CCGs.

11. Our transformation priorities

11.1 Following the publication of Better Health for London, the London

Commissioning System Design Group was established with representation

from London’s 32 CCGs and NHS England (London Region) to take

forward the planning of the delivery of the recommendations made to the

NHS in London.

11.2 The London Commissioning System Design Group has agreed four

priority clinical transformation programmes to be taken forward:

Urgent and emergency care;

Children;

Mental health;

Cancer;

Prevention; and

Homeless services.

11.3 The individual scope of these programmes are currently being considered

between commissioners along with the timeframe for delivery to ensure

the momentum for implementation of the recommendations is maintained.

The fundamentally different way of viewing the population outlined in

Better Health for London will be core to the development of the

programme scopes to ensure the different needs and expectations of

different population groups are reflected.

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11.4 To support the delivery of the clinical priority transformation programmes,

a number of priority enabling transformation programmes have also been

agreed:

Primary care;

Business intelligence and interoperability;

Estates;

Engagement;

Payments and funding;

Specialised commissioning; and

Workforce.

11.5 Similarly to the clinical priorities, the individual scope of the enabling

programmes are currently being considered between commissioners

along with the timeframe for delivery to ensure the momentum for

implementation of the recommendations is maintained.

11.6 London’s CCGs and NHS England (London Region) are committed to

working with our partners to continue to develop the exact scope of these

programmes and outline the resources required to deliver them. The aim

of these programmes will be to address the recommendations set out in

both Better Health for London and the Fiver Year Forward View. Through

implementing these recommendations we will strive to truly transform

health and care for Londoners and deliver the improvements in health,

care and outcomes that we all aspire to achieve.

11.7 At the time of writing, the London Commissioning System Delivery Group

have agreed to take forward the priority programmes outlined in the

previous section and is working to agree the exact scope and timeframes

and the associated resources required. It is expected that these will be

agreed by the end of December 2014.

11.8 By the end of March 2015 it is expected that the level of investment

required will be established and a commitment made to the

Transformation Fund to drive these transformation programmes forward.

11.9 In recognition of the considerable amount of work to do to mobilise what is

being proposed, NHS England (London Region) has agreed to pump

prime the initial process of establishing the transformation programmes

and the governance arrangements to support them. To do this NHS

England (London) will make available £1 million of funding for 2015/16.

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12. Summary

12.1 We hope that you have found this response to be useful and we look

forward to hearing more from you. We recognise that implementation of

the recommendations will require action at all geographic levels –

borough, CCG, Strategic Planning Group and pan-London – and across

all parts of London and nationally. We are looking forward to working with

our partners across London to secure the opportunity that Better Health

for London provides to us as commissioners of healthcare in London, to

make implementation of the recommendations a reality for the benefit of

Londoners – to truly make London the healthiest global city.

12.2 We hope this response has demonstrated real commitment to

transformational change and making the recommendations a reality for

Londoners and hope that this commitment will be matched by our partners

and the Mayor.

References 1 Department of Health (2013) “NHS Outcomes Framework 2014/15”

2 Department of Health (2013) “The NHS Constitution: the NHS belongs to us all”

3 Mayor of London (2014) “London Mental Health: the invisible cost of mental ill

health”

4 GP patient survey 2012/13