This meeting was to provide an opportunity for the Joint Health Overview and Scrutiny Committee to scrutinise the North West London Integrated Care System (NWL ICS)'s plans for Winter, and to review their progress on tackling health inequalities.

The only information available about this meeting is the document pack that was provided to attendees. As such, it is impossible to know what was actually discussed during the meeting, or what decisions were made.

North West London Winter Campaign and London Ambulance Performance Update

The most significant item on the agenda was an update on the NWL ICS's plans for Winter.

The report pack says there are a number of risks to the healthcare system this winter, including:

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

The report says that wait times have improved significantly in the last year but that many of our residents are currently unable to access urgent care in a timely manner. The report says that demand for hospital beds is being driven by rising acuity and our frail, elderly, 65+ population .

The NWL ICS has taken a number of steps to increase capacity and resilience during Winter, including:

• Each hospital Trust¹ has an improvement plan that has been reviewed by the Acute Provider Collaborative (APC).
• Virtual wards² are operational across the NWL ICS.
• Urgent Community Response teams are exceeding their target of responding to 90% of referrals within 2 hours.
• £20.2m from the Additional Discharge Fund (ADF)³ has been used to increase capacity in bridging care services⁴, so people can return home up to 5 days earlier while decisions are made about their long-term care.
• The ADF has also funded schemes to reduce the amount of time people stay in hospital if their care needs are complex, such as when commissioning gaps, mental health or specialist placements may be needed.
• The report says that the COVID-19 vaccination campaign will end on 20 December 2024, and the seasonal influenza campaign will end on 31 March 2025. According to the report, there is sufficient capacity for people to get vaccinated across NWL.
• There are 188 community pharmacy sites across NWL where people can get both their flu and COVID-19 vaccinations at the same time.
• UCLH's Find and Treat team, commissioned by NHS England, are working across NWL to deliver vaccines to vulnerable health inclusion groups , which include homeless people.
• The NWL Roving Team are creating tailored communications for each community and each event to increase uptake within diverse populations.
• NWL has adopted NHS England's model for respiratory care, which aims to address the needs of almost 23,000 people living with COPD⁵ in NWL.
• NWL is implementing a proactive, population health approach to reduce respiratory exacerbations, hospital admissions and health inequalities. This includes supporting GPs to better manage respiratory patients, increasing enrolment in pulmonary rehabilitation⁶, and promoting smoking cessation.
• NWL is running a campaign to promote smoking cessation via its MyHealth London and Know Diabetes digital platforms.
• The report says that Primary Care Networks (PCNs)⁷ have good utilisation and are providing a range of services including long term condition management, screening and diagnostics.
• NWL is working with PCNs to maximise the use of their Enhanced Access Capacity during Winter.
• Out of hours GP services operate from 3 sites in NWL, with a fourth site due to open in December 2024. These services are in addition to existing remote consultation and home visiting services.
• The report says that the Urgent dental service will operate 24/7 across NWL offering on the day and evening appointments, bookable via 111.
• The Pharmacy First initiative, launched on 31 January 2024, has expanded the scope of services offered by community pharmacies so they can now diagnose and treat 7 common clinical conditions, including sore throat, urinary tract infection, severe otitis media, and acute sinusitis. According to the report, 90% of people who use Pharmacy First services are treated by the pharmacist.
• NWL is also running a campaign to promote the use of Pharmacy First and emergency contraception services during the Winter.
• The report highlights the range of support available to people with mental health issues, including increasing access to mental health crisis assessment services and lighthouses, and increasing the availability of mental health beds.
• It also notes the range of support available to homeless people, including in-hospital homeless health teams and the Severe Weather Emergency Protocol (SWEP)⁸, which is triggered whenever the temperature is forecast to reach 0°C.
• CLCH's Homeless Health service works closely with hospital teams to provide continuity of care to homeless people across all NW London boroughs. They also provide outreach support to people with complex needs in Brent, Ealing, Hammersmith & Fulham, Kensington & Chelsea and Westminster.

The London Ambulance Service (LAS) has also produced its own Winter plan. This plan notes that the LAS is receiving 9% more 999 calls than last year, and if this trend continues, the average response time for a category 2 response⁹ could reach 57 minutes and 10 seconds.

To try to mitigate the risks this poses to patients, the LAS's plan:

• Increases operational staffing to meet the expected increase in demand.
• Creates a 7-day-a-week Winter delivery cell.
• Maximises the use of 999 'hear and treat'.
• Creates specific mechanisms for referring patients to their GP from the LAS.
• Maximises 'Fit to Sit' for suitable patients.
• Creates an earlier and simpler process to implement LAS cohorting.
• Designates LAS clinicians as 'Trusted Assessors' so they can refer patients to services like Same Day Emergency Care (SDEC) without the referral being reviewed by another clinician.

The LAS plan also includes a 'Patient Flow Framework', which is an escalation ladder to help the LAS and hospitals manage ambulance handover delays. The plan says that progression through levels is not linear (i.e. it is possible to move from BAU to any level straight away if the situation on the ground requires it) . The six levels of escalation are:

• Business As Usual (BAU) - patients are conveyed to their nearest hospital.
• Level 1 - Intra Trust - patients are diverted to another ED in the same Trust.
• Level 2 - Next nearest ED within ICS - patients are diverted to the next nearest ED within their ICS.
• Level 3 - Cascade within an ICS - patients are diverted to other hospitals within their ICS.
• Level 4 - Cascade divert across an ICS area - patients are diverted to hospitals in a different ICS.
• Level 5 - Redirect - only blue light calls and patients who need specialist care are taken to the nearest ED.
• Level 6A and 6B - Full closure - The ED or Hospital is closed to all ambulance conveyances, which are redirected to the next nearest ED.

The LAS plan also proposes two new levels to the LAS's Clinical Safety Plan (CSP), which it says will be activated in response to sustained UEC system pressure . The two new levels are:

• Red - An ICS-specific response that is triggered when:
  • Category 2 response times are greater than 45 minutes in the affected ICS for a sustained period after midday.
  • Average hospital handover time is above 26 minutes in the affected ICS.
• Purple - A pan-London response that is triggered when:
  • Category 2 response times are greater than 60 minutes for a sustained period after midday across all of London.
  • Average hospital handover time is above 26 minutes across all of London.
  • There is evidence of a significant respiratory illness in the community .

The actions to be taken in response to each escalation level will be agreed by the ICS. The report pack says that system agreement is needed to move to red and purple levels .

North West London Health Equity Programme

The second most significant item on the agenda was a report on the North West London Health Equity Programme.

The report says that people in the most diverse and deprived communities in NWL are dying earlier than they should , and that as well as the ethical and moral imperative to reduce health inequalities, there is also a financial imperative as this has an impact on longer term resources .

The report notes that:

• The most deprived decile in NW London are becoming multi-morbid around 10-15 years younger than more affluent areas.
• People in the most deprived neighbourhoods in NW London are dying up to 20 years earlier than people living in the least deprived areas.
• In Kensington and Chelsea, life expectancy can drop by 15 years within a 15 minute walk.
• People from Black and Black British ethnicities are 1.6 times more likely to be multi-morbid than White ethnicities.
• The rate of unplanned bed days in the most deprived group is around 1.2 times higher compared to the least deprived group.

The report suggests that a range of factors contribute to this gap in healthy life expectancy, including inequalities in social, economic, and environmental factors. It says that unemployment is almost twice as high in the most deprived quintile for men in NW London, and that adults in the most deprived quintile are 1.5 times more likely to have a poor diet. The report also highlights that communication barriers, digital exclusion, and a lack of culturally sensitive healthcare services can all contribute to health inequalities.

The Health Equity Programme is arranged around 3 pillars:

1. Clinical Care - which is based around NHS England's Core20Plus5 framework.
2. Population Health Management - which focuses on developing the skills of staff to deliver the 'Focus-on' PHM methodology.
3. Wider Determinants of Health - which focuses on the social, economic and environmental factors that affect health.

The long term ambition of the programme is to reduce disparities in healthy life expectancy, by:

• Increasing the age at which 50% of the population in the most deprived quintile are multimorbid, from 55-59 years to 65-69 years.
• Reducing emergency admissions due to ambulatory care sensitive conditions¹⁰.
• Reducing the inequality gap of life expectancy in NWL from 20 years to 15 years.
• Reducing preventable deaths under 75 in NWL to less than 200 per 100,000 people.

The programme has delivered a number of achievements in the last year:

• The Health Inequalities Transformation (HIT) Fund has awarded around £8m to NWL to support transformational activity at all levels of the system.
• A Core20Plus5 Community of practice has been set up to discuss and resolve equity issues.
• The programme is working to embed a core set of health inequalities metrics in each of its programmes, and is already seeing improvements in metrics such as hypertension control and access to Know Diabetes.
• The 2024 NW London Health Equity Summit was attended by around 200 people.
• The Race Equality Steering Group has commissioned an Independent Report into Barriers to Leadership.
• Work has begun to implement recommendations to address digital exclusion, including investment in training to build skills in communities and improving commissioning of NHS online services.
• Two well-attended large scale community in-reach events have taken place, leading to the creation of an on-going cross-system in-reach model.
• The NW London PHM and Health Equity Academy has been established, which provides staff with opportunities to develop their skills in population health management, including co-production and health economics.
• The Shared Needs Assessment has been finalised and published.
• The WorkWell programme, which aims to support people from Core20Plus communities into employment, has launched and has already received 279 referrals.
• Several projects are progressing to promote prevention and healthy living, including the healthy weight project and additional investment in tobacco cessation pathways in the NHS.
• The Anchor Charter is in place, and a Community of Practice has been set up to share best practice and build momentum.
• All NHS Trusts in NWL have now committed to paying the London Living Wage.
• Work is underway to better integrate VCS organisations into decision making and contracting processes.
• A number of projects have been funded to address specific local issues, including improving early cancer detection, improving oral health, building digital inclusion, and embedding equity in acute providers.

Integrated Care System Update from the Chief Executive of the North West London ICS

This item included a report from Rob Hurd, Chief Executive of the NWL ICS.

The report notes that:

• Over 95,000 people responded to a recent survey on access to general practice, and that each of the 45 PCNs in NWL are invited to hold at least two events to discuss access to services with their patients.
• Funding is available for PCNs and practices who develop proposals to improve patient access, and any changes should be co-designed and localised to best meet the needs of local residents.
• NWL NHS is holding a public consultation called Compassionate care for all on proposed improvements to adult community specialist palliative care.
• NHS England is making plans to consult on proposed changes to services provided at Mount Vernon Cancer Centre, including its relocation to Watford General Hospital.
• NWL had 3 winners in the Health Service Journal (HSJ) Awards, which recognise outstanding contribution to healthcare.
• The NWL Refugee Employment Programme won NHS England's award for Collaboration and Partnerships.
• The Chiswick PCN Pharmacy Team was shortlisted for Pharmacist/Pharmacy Team of the Year Award.
• WorkWell, a project that bridges employment and health equity in NWL, has shown strong initial traction, receiving 279 referrals in October 2024.
• The Hounslow Integrated Discharge Hub scored outstandingly high on the recent Transfer of Care Hub maturity matrix.
• Work is underway to develop a revised NWL Estates Infrastructure Plan and NWL ICS Estates Strategy.
• Estates rationalisation has now concluded across the 8 boroughs.
• NWL has secured the largest allocation of Community Infrastructure Levy (CIL) and s106 funding of any ICB in London.
• Several estates projects are due to complete this financial year, including the relocation and refurbishment of Hillcrest Surgery in Ealing, the expansion of primary care at Grand Union Village in Ealing, and the delivery of a new primary care facility in South Kilburn in Brent.
• Applications for London Improvement Grant funding for FY 24/25 are moving through final due diligence.

North West London JHOSC Recommendations Tracker

The final item on the agenda was a report on the NWL JHOSC's recommendations tracker, which provides a summary of scrutiny recommendations made by the committee to the NWL ICS. The report pack included two appendices, one for the 2023/24 municipal year and one for 2024/25.

The 2023/24 tracker shows that the committee made a number of recommendations to the NWL ICS, including:

• To receive ongoing updates regarding extra capital funding for acute beds in relation to winter pressures.
• To receive more detail on horizontal and vertical working between community and acute settings and how this is working in practice across North West London.
• To receive updates on the work undertaken by Acute Trust and the ICS to progress the work at delayed hospitals in the New Hospitals Programme.
• To receive more details on the ongoing engagement work related to the standardisation of ophthalmology services.
• To receive more information on how the standardisation of ophthalmology services will address health inequalities in North West London.
• To receive baseline data on performance in ophthalmology services in order to measure performance in North West London against national and London standards.
• To ensure that diagnostic capacity across North West London is properly linked to musculoskeletal services.
• To receive baseline access wait times for musculoskeletal services and details on how the new service standards will improve waiting times for treatment.
• To provide information on where the gaps in resource with palliative and end of life care are, how they will be addressed and how this will be monitored.
• To provide a report around mental health provision for children and young people to come to a future JHOSC meeting.
• To receive the details of the alternative provision to accident and emergency located across the boroughs.
• To receive further details around on the engagement plans when available.
• To receive more information around plans or existing activity to support people and communities in deprived areas or intersectional needs.
• To provide details of the commentary and output of the pre-consultation workshops on the future of the Gordon Hospital, the completed and upcoming events with service users and carers, service users’ experience of Gordon Hospital, a more detailed consultation plan, historical reports of Gordon Hospital service users over the last 5 years, and historical demographic data of Gordon Hospital service users.
• To provide an update to the Committee once NHS have assessed the Government’s new position on immigration and how this might affect recruitment and workforce within North West London.
• To provide an update of progress by the Race Equality Steering Group.
• To provide regular updates on progress of the seven priority workstreams.
• To report to the Committee on the success against metrics and targets identified for the Orthopaedic Centre and also get feedback from staff and patients.
• To report to the Committee on the operation of the dedicated transport provision.
• To bring a report to the Committee once there are more detailed plans available on the redesign and consultation of the ICS.
• That NWL NHS undertake an Equality Impact Assessment and Human Rights Impact Assessment prior to implementing any changes in the way patients access primary care.
• That the Committee should seek meaningful consultation with patients, communities and GPs. Any engagement undertaken should be representative of the whole patient voice.
• To provide feedback and analysis of the impact of the early adopter PCNs, including case studies that have been learned from.
• To receive full details of how patient safety and effectiveness would be measured against the proposals.
• To receive information on the outcomes of the work done by KPMG in a way that was easy to understand and that related to patient outcomes.

The 2024/25 tracker shows that the committee had already made three recommendations by the time this meeting was held:

• That NWL NHS consider lessons learnt from previous consultations such as the Gordon Hospital to ensure that the complexity in working with multiple and hard to reach communities and stakeholders is considered throughout the consultation and engagement processes to ensure meaningful insights are acquired resulting in effective decision making.
• That NWL NHS take proactive actions with hospitals and clinicians to ensure patients and families have all the information they require in advance regarding their options for end-of-life care planning and support available for families.
• That members of the committee provide a list of locations in their borough to Chatan highlighting suitable places for drop-in sessions and consultation activities to take place as this could result in enhanced engagement with residents. Chatan to then collate a list and pass on to the NWL NHS Engagement Team.
• For the JHOSC to be presented with a further, more detailed report on the NWL Mental Health Strategy detailing what the strategy actually entails, it’s priorities and a plan on how the new strategy will deliver on outcomes and priorities.
• To provide a borough-by-borough breakdown of those with Severe Mental Illness (SMI) across NW London. The information should include a more detailed breakdown of what has already been provided to the committee including conditions per borough and actual numbers on prevalence rather than percentages.
• That future communication plans and survey questionnaires, not only for this item, but also for future planned work and consultations are shared with the committee in advance for comments to ensure effective questioning and constructive discussions can take place at JHOSC meetings.