The North West London Joint Health Overview and Scrutiny Committee was scheduled to discuss the North West London Integrated Care System’s (NWL ICS) plans for the winter of 2024, receive an update on the NWL ICS from its Chief Executive, and review recommendations made to the ICS by the committee in previous meetings.

NWL ICS Winter Plans

The NWL ICS plans aim to mitigate the risks to patients in the community that are posed by the predicted increase in demand for urgent and emergency health care in North West London over winter 2024. The report pack identifies a number of key risks that are posed by winter pressures, these include:

• Workforce Capacity
• General bed capacity & reporting
• Avoidable admissions to hospital
• Delays in discharges from hospitals
• Availability of medicines
• Accident & Emergency (A&E) waiting times
• Ambulance handover and response times
• Acute respiratory infection

The report pack describes the actions being taken by the NWL ICS to mitigate the risks posed by these winter pressures, which include a number of schemes intended to improve the flow of patients through the health and care system. For example, each Trust in North West London has developed an improvement plan, which includes:

• A consistent approach to streaming & redirection
  • How to maximise the use of Urgent Treatment Centres (UTCs)
  • Increasing the utilisation of same day emergency care (SDEC) and delivery a consistent approach across the sector that’s compliant with national standards.
  • Provide an Acute Frailty Unit response on a 10/7 basis
  • Actions to reduce ambulance handover delays
  • Actions to reduce waiting times in EDs, focussing on both the admitted and non-admitted pathways
  • Reduce the number of patients past their Discharge Ready Date (DRD)
  • Maintain acute G&A bed capacity at the level agreed through the operating plan
  • Paediatric ED performance, with actions being taken forward from last year’s Paediatric ED peer review
  • For 999 pathways the major focus is the development of an Integrated Co-ordination Centre in line with national guidance. This will include pathways such as call to convey and put a platform in place for 999, 111 and EDs to work in a joined up way with community providers

The NWL ICS is also operating virtual wards to avoid unnecessary admissions to hospital:

Virtual wards are operational across our trusts with a number of pathways now live. Utilisation has improved to 82.6% in October with a trajectory in place over winter, and patient feedback is notably positive. Development of a new pathway for Acute Medicine Pathway will shortly commence. PATCH pilots in NW London provide alternatives for families who can’t support hospital at home arrangements.

In recognition of the fact that a swift discharge to an appropriate setting reduces pressures on the system, a Quality Summit was held in September 2023, which was attended by all Directors of Adult Social Services (DASS), and clinical and operational representatives from across the ICB. The Summit was intended to identify best practice and share it across sites, and to discuss how to improve the speed of discharges in the context of needing to go “further and faster for winter 23-24”. This has informed the work programmes for 2024-25 in which the Borough Based Partnerships (BBPs) are the key to ensuring join-up and escalation where delivery is impacted.

The ICB is also taking steps to prevent unneccessary exacerbations of long term conditions, including delivering effective immunisation strategies for COVID-19 and seasonal flu. The report pack sets out the eligibility criteria for the vaccination programmes and describes how the ICS is working to reach all eligible communities, including hard-to-reach communities and communities where vaccine hesitancy may be an issue. For example, the ICB is providing outreach immunisation services through the NWL Roving Team and UCLH’s Find and Treat service. The ICB is also supporting people with long term conditions, and in particular people with Chronic Obstructive Pulmonary Disease (COPD), through the implementation of a proactive, population health approach to respiratory care.

The London Ambulance Service’s (LAS) plan for winter 2024-25 proposes a number of actions that will require the agreement of the London system. These include:

• Agreeing patient groups where the LAS can refer direct to GPs
• Agreeing new 'fit to sit' criteria to ensure that only those who need to be conveyed to hospital by ambulance are conveyed to hospital.
• Agreeing a simplified LAS cohorting process. Cohorting takes place when an ambulance crew has to wait for more than 15 minutes to hand a patient over at an A&E department. Where cohorting is in place, ambulance crews hand their patients over to another clinician, usually a nurse, so that they can be released to respond to other calls.

The plan also proposes a six-level patient flow framework, which will enable the LAS to redirect ambulance patients away from busy A&E departments. Level 1 of the framework covers 'business as usual' activity. Level 6 covers the full closure of an A&E Department:

• Level 1: Ambulance patients are conveyed to the nearest hospital unless the tertiary centre guidelines are met
• Level 2: Ambulance patients are conveyed to the next nearest A&E department within the same ICS
• Level 3: Ambulance patients are conveyed to all or selected hospitals within the ICS
• Level 4: Ambulance patients are redistributed to A&E departments in other ICSs
• Level 5: Only emergency calls, and patients requiring specialist care are conveyed to the compromised A&E department. Other patients are conveyed to other A&E departments
• Level 6: The A&E department is closed. All patients are conveyed to the next nearest appropriate A&E Department

The plan proposes two new escalation levels, which will trigger specific actions by the LAS and the wider healthcare system:

• Red: Declared by an individual ICS when Category 2 response times exceed 45 minutes after midday. Where red escalation is declared, ambulance crews will spend less time with patients on scene, and hospitals will be expected to prioritise emergency care for patients who cannot be seen by the ambulance service, such as people experiencing mental health crisis and fallers
• Purple: Declared London-wide when Category 2 response times exceed 60 minutes after midday, or when London is experiencing significant levels of respiratory illness

The report pack also includes the NWL ICS communications and engagement plan for winter 2024-25. The plan aims to support local residents in making decisions about their health and the services they use, by providing information and redirecting people at the point of need. The communications strategy will be informed by data from the Whole Systems Integrated Care Dashboard.

NWL Health Equity Programme

The committee was scheduled to receive an update on the work of the NWL Health Equity Programme. The Programme aims to address the fact that people in the most diverse and deprived communities in NWL are dying earlier than they should. The report pack notes that:

In NW London, in our more deprived neighbourhoods, people are dying up to 20 years earlier than their peers. Within Kensington and Chelsea you can walk 15 minutes and the life expectancy will have dropped by 15 years.

The Programme aims to address the range of factors that contribute to this gap in healthy life expectancy, including social, economic and environmental factors, the lack of an environment which supports healthy behaviours and lifestyles, the lack of culturally competent services, and inequalities in access to proactive and preventative care. The programme has three pillars:

1. Clinical Care: NHS services, providers and commissioners are working to improve outcomes for our most deprived and marginalised groups, using NHS England’s Core20Plus5 framework.
2. Population Health Management: The programme is supporting the development of key skills to deliver the locally produced ‘Focus-on’ population health management methodology, with Integrated Neighbourhood Teams (INTs) being the key vehicle for delivery.
3. Wider Determinants of Health: The programme is working with local authorities and the voluntary and community sector to address the wider determinants of health and health behaviours

The ultimate, long-term, ambition of the programme is to reduce disparities in healthy life expectancy, using four metrics:

1. Increasing the age of the most deprived quintile where 50% of the population is multimorbid
2. Reducing emergency admissions due to ambulatory care sensitive conditions
3. Reducing the inequality gap of life expectancy in NWL
4. Reducing preventable deaths under 75 in NWL

The programme has a range of mechanisms for engaging and consulting with diverse communities:

1. Tailored communications: Using culturally appropriate messaging, distributing updates through trusted community leaders, and leveraging digital tools and in-person outreach
2. Building trust and accessibility: Establishing a Co-Design Advisory Body, developing an in-reach programme for excluded communities, and completing a gap analysis to identify communities not currently being reached.
3. Community-centric engagement: Co-designing services with community representatives, hosting regular drop-in sessions in accessible locations, and introducing peer-led focus groups.
4. Commitment to equity and inclusivity: Monitoring engagement and consultation outcomes, and training staff and volunteers in cultural competency and trauma-informed approaches.

The Programme has made progress on all three pillars, including:

• Establishing a Core20Plus5 community of practice
• Working with the NWL Race Equality Steering Group to support the establishment of the African and Caribbean Think Tank
• Supporting borough work to build trust at place level
• Establishing the NWL Population Health Management and Health Equity Academy
• Publishing a Shared Needs Assessment report
• Launching the WorkWell programme
• Investing in tobacco cessation pathways
• Working to support better integration of VCS organisations in decision-making and contracting processes.

The report pack includes a number of case studies that illustrate some of the initiatives that are being delivered to improve health equity in NWL. These include:

• Screen, Detect, Protect: A project aimed at improving early cancer detection in marginalised communities. The project has seen improvements in cervical screening rates across proxy populations, with a 15.77% change in uptake for people with learning disabilities.
• Hounslow Health Outreach Team: Has reached over 20,000 residents, focusing on Core20Plus populations, helping to close gaps in health service awareness and access. The Team has led to a 17.2% increase in vaccine uptake in targeted areas, the identification of 709 potential hypertension cases, and improved engagement with communities such as traveller groups.
• Cross-system oral health plan: A partnership working across NWL to create a joined-up oral and dentistry plan, using HIT funding to implement best practice e.g. CYP brushing for life packs & education materials directed at deprived areas.
• Community in-reach events: Two large-scale co-designed events to connect the black community into the health system, building trust, and offering a more holistic, culturally appropriate approach, aligned to the wider prevention agenda.

NWL ICS Update

The committee was scheduled to receive an update from Rob Hurd, the Chief Executive of the NWL ICS.

Mr Hurd's report highlighted the financial pressure on the ICB, and stated that the ICB would not be issuing ‘commissioning intentions’ because “our plans are set out in the Joint Forward Plan, which is agreed through the ICB Board and local Health and Wellbeing Boards.”

Mr Hurd’s report also described the NHS Ten Year plan and confirmed that another large NHS reorganisation is not happening, stating that ICBs are central to ‘self-managing, self-improving systems’ and critical to delivering the ‘three shifts’ the government is seeking: from treatment to prevention, from analogue to digital and from hospital to community. ICBs “will continue to be the system leader for the NHS, convening and working across all key partners within their integrated care system”.

The report included an update on the NWL ICS’s “Compassionate Care for All” public consultation on community-based palliative care services, which aims to ensure compassionate, high-quality support for those facing serious or life-limiting illnesses. The report set out the proposed improvements to community-based palliative care services, and describes the two options being consulted on.

The report also provided an update on the proposed relocation of Mount Vernon Cancer Centre, from Mount Vernon Hospital in Northwood, to an acute hospital site at Watford General Hospital. The proposals include relocating services to Watford General Hospital, expanding chemotherapy services at Northwick Park Hospital, introducing a chemotherapy-at-home service, and providing local blood testing facilities. A public consultation is planned for early 2025.

Mr Hurd's report also included an update on the newly established Joint Health Scrutiny Committee, which is being established between ten local authorities, including the London Boroughs of Harrow, Hillingdon, Brent and Ealing. The committee will be chaired by the Hertfordshire Health Scrutiny Chair with Hillingdon Health Scrutiny Chair in the role of vice chair. Its first meeting is scheduled to take place in mid-December 2024.

The report also celebrated the recent achievements of the NWL ICS, including three wins in the Health Service Journal Awards, and an NHS England award for the NWL Refugee Employment Programme. The report also provided updates on the ICB’s WorkWell Programme and the Hounslow Integrated Discharge Hub, which scored outstandingly high on the recent Transfer of Care Hub (ToCH) maturity matrix.

The report also provided an update on the NWL ICS’s estates programme.

NWL JHOSC Recommendations Tracker

The committee was scheduled to review the tracker of recommendations made to the ICS by the committee in previous meetings.

The report pack includes trackers for the 2023/24 and 2024/25 municipal years. The trackers provide a summary of recommendations and information requests made by the committee. The trackers show whether recommendations have been accepted or rejected by the ICS and provide updates on the progress of recommendations that have been accepted.

The 2023/24 tracker included recommendations on:

• Acute beds
• Ophthalmology
• Musculoskeletal (MSK) services
• Proposals on the future of The Gordon Hospital
• ICS workforce strategy and programme
• NWL Elective Orthopaedic Centre
• ICS running costs reduction
• Primary care access and same day access model

The 2024/25 tracker included recommendations on:

• The NWL Adult Community-based Specialist Palliative Care (CSPC) review
• The NWL Mental Health Strategy
• NWL primary care access