All 32 London clinical commissioning groups and NHS England’s London arm have set out plans to drive the improvements called for by the NHS Five Year Forward View and the London Health Commission.
Every CCG has committed 0.15 per cent of their budgets to create a shared fund to make improvements to healthcare across London. NHS England said this would come to “in the region of £20m”.
It is not yet known how much NHS England will contribute. A spokeswoman for NHS England said it was “still defining total investment”.
The groups have come up with 13 programmes where improvements could be made. These programmes include work to:
- develop an urgent and emergency care network across the city;
- address the poorer health outcomes in London for children and young people compared to the rest of the country;
- address the life expectancy gap for people with severe and lasting mental health issues;
- improve early detection of cancer;
- invest in primary care;
- give CCGs greater control over specialised commissioning; and
- improve homeless healthcare services.
Each programme has a clinical lead and chief officer lead from one CCG.
Work is already underway to make improvements to primary care in London, but the other programmes are in their early stages.
In an interview with HSJ Anne Rainsberry, NHS England regional director for London and co-chair of the capital’s primary care transformation board, said the strategy had deliberately avoided a prescriptive approach to how change can be implemented.
She said: “We quickly got to the point of saying that trying to do ‘one size fits all’ around London and imposing a particular model of care just wasn’t going to get anywhere, we couldn’t get the bottom-up energy for that. Very consciously with this work we’ve got the ‘what’, and all the work of vanguards and new models of care are clearly a way of informing the ‘how’ but we aren’t prescribing to local communities the ‘how’.
“We may have large organisations that house multiprofessionals and that may fit Havering but it may not fit Tower Hamlets.”
Ms Rainsberry said that in London 92 per cent of the budget goes on “things other than primary care, mostly in hospitals”.
She said the move to transfer “between 0.7 to 1.5 per cent of total spend” into primary care over five years, as proposed in the primary care strategy, would not be a “massive shift”.
She added: “I’m not in any way saying that isn’t difficult to do given all the pressures on the service but it’s just to frame it that it might be possible actually.”
Caution over devolution for London
Ms Rainsberry expressed caution over recent calls for London to be given a devolved health budget, as announced last month for Greater Manchester.
She said: “There’s recognition that what Manchester’s done would be very difficult to translate to a place like London. There are 33 boroughs, and the [Greater London Assembly] which is a very different dynamic.”
She added that while there was a “conversation to be had”, devolution “for devolution’s sake” should be avoided.
She added: “If we’re all signed up to that and we can deliver that vision in the context of the [forward view] with faster, better outcomes and better value that is a conversation worth having.”
Primary care has had “virtually no investment” in over a decade, according to Clare Gerada, chair of the primary care clinical board.
The strategy estimates that primary care will require an investment of £310m-£810m a year over the next five years to tackle workforce and estate issues.
Dr Gerada said: “A third of all our practices in London are not [Disability Discrimination Act] compliant. There has been virtually no investment in primary care estate for probably a decade and a half – proper investment, not these new build, all singing, all dancing health centres – and you’re beginning to see the creaking… they’re not fit for purpose for the modern world.”
It is expected that GP practices will need to form federations to make improvements and that contracts should be offered to GP federations or multispecialty community providers delivered across wider populations, rather than individual practices, according to the strategy.
Dr Gerada said: “I think over time what we’ll see is a much more robust system where you’ll probably get populations of maybe 50,000-100,000 with acute trusts [and] mental health trusts, in order to deliver these standards and to have population based outcomes.”
However, she added that non-geographical federations like the Hurley Group, where she is a partner, would not be forthcoming.
She said: “What I don’t think is going to happen in terms of structure is the sort of organisation that we run, the Hurley Group. I don’t think you’re going to get non-geographical GP federations. We were testing out different models and it’s worked, but I think rightly we should be looking at populations that are geographically aligned.”
The organisations leading the programmes would vary depending on the scale of the challenge.
Andrew Eyres, chair of the chief officer’s group for London CCGs and chief officer of Lambeth CCG, said: “A lot of things will happen at a borough level, some at a strategic planning group level and some things you get real benefit from working across the whole of London.”
He added: “The governance structure is drawn from NHS England and CCGs at the moment, but the first job we’ve given it to do is to think about how it’s going to engage with its broader stakeholders as well.”