Agenda item

To present the Brent Health and Wellbeing Board with an update on the work of the Integrated Care Partnership (ICP).

Janet Lewis (Director of Operations for CLCH) introduced the report, which provided an update on the setup and progress of community health services in Brent as part of the new Integrated Care Partnership (ICP). Central London Community Healthcare (CLCH) were the current provider for Brent Community Services following the transfer from London North West Hospital Trust (LNWHT) on 1 August 2021. The Board were advised that CLCH as a provider sat within the NWL Integrated Care System (ICS), and sat within the Brent Integrated Care Partnership (ICP) as part of that system. Within the ICP executive there were 4 priorities, agreed following feedback from stakeholders and Brent residents, one priority of which included community services. A Community Services Executive Group had been set up which Janet Lewis co-chaired with Simon Crawford (Director of Strategy and Deputy CEO, London North West Healthcare NHS Trust) with wide stakeholder engagement. They were looking to include voluntary groups and third sector organisations in that group at a strategic level.

In updating the Board on community services, Janet Lewis advised that the first piece of work conducted was to safely transfer community services from LNWHT to CLCH. She expressed that throughout the period of transition it had been a pleasure to work with the acute hospital trust, the ICP, the Council and others to ensure the transfer was safe for patients within Brent and that 400 staff members were safely transferred from the acute hospital to CLCH. She advised that there had been some small challenges during the transfer, such as maintaining IT systems, but on the whole it was a successful transfer which was monitored through a mobilisation board that fed into the ICS regularly.

In terms of the priorities of the Community Services Executive Group, Janet Lewis advised that many aligned with the NWL ICP priorities. The priorities focused on planned care, such as district nursing, tissue viability, and in-reach in care homes to standardise care across NWL and ensure services were provided as close to home as possible. The aim was to work at a local level because patients wanted to access services much closer to their homes. Priorities also focused on unplanned care and the need to ensure the rapid response service within Brent was maintained to prevent hospital admissions. The Board were advised patients appreciated that they could have frontline care and management in their own homes with an assessment of whether hospital care was required. The Executive Group were also making sure children’s community services were aligned with the work of the Brent Children’s Trust so there was no duplication. Work on rehabilitation and reablement was in progress, in order to deliver those services in a more integrated way. Work in care homes was being prioritised, focusing on improving 9 care homes in the Borough rated by CQC as ‘needing improvement’. This was being done through a peer support programme, and those care homes who had been engaged were transitioning nicely to moving out of requires improvement. The Board heard that the work would continue until all Brent care homes were rated as ‘good’, if not ‘outstanding’. Continuing to detail the work going on in care homes, Janet Lewis advised that the work to vaccinate care home residents was continuing, as well as the mandatory staff vaccinations needing to be administered by 11 November 2021.

The Board were advised of the work on the hospital discharge process, working with LNWHT as the core provider around discharge hubs. There were now integrated posts to ensure patients were discharged in a timely and appropriate way on the correct pathway, with NWL having an integrated discharge system across the whole of its providers to ensure a joined up model. As the hospitals moved in to winter, the Board were advised that winter planning would be a key part of the work of CLCH, to ensure rapid response teams could keep patients at home with the back-up of other community services in order to stabilise the patient.

Simon Crawford added that Northwick Park Hospital for the past 8 weeks had been under severe pressure and often had 20+ patients waiting for access to a bed on Monday mornings. For that reason, he advised it was critical the discharge pathway worked as seamlessly as it could, and felt that it was working extremely well. The support the hospital had received had allowed those pathways to be seamless in terms of accessing care homes and care plans and accessing social worker assessments. He informed the Board that LNWHT for the past 6 months had been in the top 7 in London, out of 21 providers, for 7 day length of stay performance. The provider had also been the top 4 performer for 14 days length of stay, and the top 3 performer for 21 days length of stay where previously it had been towards the bottom. The challenge for LNWHT as an acute trust provider was around the volume of patients entering the Urgent Treatment Centre and finding alternative pathways for them in the community, and a focus for the next three months would be how patients could be provided with proactive care in the community.

The Chair thanked health colleagues for their introductions and invited comments and questions from those present, with the following issues raised:

·         In relation to the user perspective, the Board queried whether there was a written down process on the discharge pathway for patients and their families, in order for them to know what to expect, particularly following unexpected hospitalisation. Simon Crawford confirmed that the patient and family were involved in those discharge plans. When the hospital was under challenge patients could not always have their first choice in terms of care home or designation, but it would always be a safe and appropriate discharge. The aim was always to get patients home with a package of care and support in a familiar environment, and the hospital worked with the discharge team supporting that as well as the Council’s social workers, who were very active in having those conversations with patients and relatives. Janet Lewis added that there may be some work CLCH could do around communication of the pathways and they were happy to review the literature. The system had learned through Covid-19 that there were 4 clear pathways which had brought clarity for patients and if the system stuck with those 4 it was much clearer and more transparent.

·         Regarding what work was being done within community services to support more discharges out of acute hospitals, Simon Crawford advised that this was often through the Trust providing advice and support on the pathways, or community services using linkages through the primary care networks (PCNs). A new forum to engage with PCNs from an acute perspective was being set up, and staff had been engaged at a primary care summit involving the 3 Boroughs LNWHT served, with different initiatives coming out of those that Brent would be looking to do. For example, in Ealing there was work being done on the heart failure lounge and acute pathways into STEC. They were also looking at the support that could be provided to patients on particular medications and looking at the hotline to access the right clinical advice. From a community services perspective, Janet Lewis advised that they were reviewing pathways for patients with specific diseases such as heart failure, respiratory conditions and diabetes. They worked closely with GPs across the PCNs to map patients who had, in the past, more than one admission, or several admissions, to manage them to remain at home. They were currently looking at how they could improve that service out of home, and were investing in additional resource for an Enhanced Home Care Team. They were also ensuring transition from the Rapid Response Team into existing community services was seamless so patients did not see a gap. She advised there was a lot of work that needed to be done but was confident they were on track with the right engagement from the right people.

·         In relation to care standardisation, Fana Hussain (Borough Lead Director, NWL ICS) advised that standardisation of primary care had been a major area of focus for the past 2 years with attention on cancer screening, prescribing and service delivery. She advised the Board that there were good pieces of work on standardisation of bowel screenings with patients eligible to receive that service. Primary care also worked with charities such as Cruise and Cancer Research to improve the uptake of those services. Additional appointments had been added for cervical screenings which included access to hubs over evenings and weekends. Where there were practices with good standards of care they were being paired up with those practices requiring additional support to keep that work an area of focus. For those practices which were not at the same level of care as others the Brent Health Matters Team were working with those to improve their standards. Dr M C Patel (NWL ICS) highlighted that PCNs needed to make a standard offer to all their residents for the services being offered to the community, therefore PCNs needed to take responsibility to look at specialist services their own practices may require. He highlighted that PCNs received considerable resource they could use to fund various initiatives. Simon Crawford added that for the discharge hubs, a standard model across NWL ICS had been agreed, which included what a hub should look like, its size, capacity and seniority. On the Northwick Park Hospital site an appointment had been made on the person that would lead that function going forward.

·         The Board queried whether care navigators and social prescribers were still part of PCNs. Janet Lewis advised that there were a range of posts within community services, such as Care Co-ordinators who sat within the district nursing services, the Community Champions and Health Educators within the Brent Health Matters Team, and Integrated Case Management Co-ordinators. Fana Hussain added that Care Navigators continued to work in Primary Care alongside Social Prescribers, Care Co-ordinators and Clinical Pharmacists, all employed by GPs through the additional role reimbursement scheme which encouraged practices to employ additional staff to support the patient population. The system was currently looking at implementing Mental Health Support Teams who would be jointly employed between CNWL and GPs.

·         In terms of communicating to stakeholders and patients, Robyn Doran advised that they would look to work with communications teams and Healthwatch to get messages out about all of the workstreams going on, and were happy to follow up on communication at a future meeting.

RESOLVED: to note the information provided in the paper, and request that the next update report includes information on the communication of discharge pathways and the various workstreams.