OUT OF HOSPITAL STRATEGY
In everything we do we believe in challenging ourselves, thinking differently and
making a difference. Our health and care system will be envied nationally and
internationally, as we deliver the care people want and need flexibly and sustainably.
We want to change the lives:
of our children and young people to ensure the best physical, mental and
emotional place moving into adulthood,
of younger working age adults who deserve 21st century ways to access
of older working age adults who need some help to be healthier, prevent
illness and stop illnesses having a severe impact on their lives
of older people to help them from becoming frail and reduce their loneliness
of our older frail population to enable them to be cared for at home for as long
We want to reshape the offer of care over the next 4 years for each population
segment described above; improving how and where care is delivered across
assessment, treatment, recovery and prevention. We will make these improvements
jointly with our patients, our residents and our providers.
We want to offer a much greater emphasis on assessment and prevention as we
strive for patients and residents to become healthier, more active and independent
people, with both their physical and mental health; however we also want to ensure
that when people need treatment it is offered as quickly as possible, in a setting that
makes sense to them and that we focus on recovery and getting people back to their
normal lives both mentally and physically as efficiently and effectively as we can.
We also want to ensure that the funding we receive for care is spent supporting
people to be well and not offering treatment once they are sick.
Enfield and North Central London: Who are we?
Enfield CCG operates within the North Central London (NCL) Sustainability and
Transformation Plan (STP) which falls within the NHS England London region.
Enfield is one of five CCG’s in the NCL STP: Barnet, Camden, Haringey and
Islington make up the other four.
Enfield has 47 GP Practices and commissions healthcare for its 344,000 population.
Enfield Council is a single unitary authority and is responsible for the care needs of
the whole population.
Circa 82% of acute patients are treated within our local hospitals, Royal Free London
(RFL) and North Middlesex University Hospitals Trust (NMUH). The remaining 18%
are treated by the local private sector or outside of our area by various hospitals,
mainly across the London area including specialist providers. By virtue of our patient
flows our activity is mainly with NMUH and the surrounding London hospitals.
Strategy Overview: Focusing on Function
This strategy develops Enfield’s long term vision for integrated, place-based
community care. The aim over the next four years is to make a real difference to how
care is delivered to our population. We will focus on getting the function (the model
of care) right whilst continuing at pace to work with our providers to develop our plan
around the future form of the Integrated Care System (ICS)
We will develop our model of care through:
Closer integration with health and social care
A clearer understanding of our local population needs (place-based)
Better management of scarce clinical resources with a single layer of
More co-ordinated care, delivered through a multi-disciplinary approach
Integrating more care functions (e.g. mental health; falls; rehab), to enhance
the ability to meet patient needs in the community
Our Integrated Primary & Community Team (IPCT) will be responsible for the
delivery of a single set of outcomes including:
Proactive care to maintain good health
Diseases well managed
Care tailored to local need
Reduced health inequalities
Residents able to live independently at home but not isolated
Acute flow reduction
Value for money from each intervention
Strategy overview: Developing Form
As a way of delivering our model of care locally, the case for change for Primary
Care Networks (PCN) is compelling. This concept is a further development of an
established principle in Enfield: clusters of practices working together to improve the
health and care for their local populations. PCN’s enable practices to use their
resources more efficiently by providing economies of scale, which mean that they can
provide more services for their patients by pooling resources to invest in technology,
estates and workforce. PCN’s will be the driver of delivery in their local area,
managing resources to provide better outcomes for people.
In our commissioning role as system facilitators we will support the mobilisation of
PCN’s through the new Primary Care Contract reforms that will go live from 1st July
2019. We will work with practices to help them understand the needs of their local
population in new ways, using population segmentation techniques, to tailor the
configuration and skills mix of the Integrated Primary and Community Team for each
PCN population. We are committed to supporting each individual practice to
develop a practice resilience plan.
At the same time as working with local practices to develop their Primary Care
Networks, over the next few months the local system will begin detailed discussions
on the development of its Strategic Integrated Care System supporting its Tactical
Integrated Care Partnerships. Our focus will be on creating a sustainable
community infrastructure that enables
all partners across a designated area to share a single, capitated budget
which provides funding for all of the health and care needs of the whole
all partners to operate within a joined up model of care (coordinated by
Primary Care Networks and delivered by GP practices, the Integrated
Community Team and our four local hubs)
all partners to work together to deliver a single, shared set of outcomes
Strategy overview: Key deliverables
An Integrated Primary and Community Team (IPCT) with a single management
structure delivered through a partnership arrangement in 2019/20 and through a
formal contract as one component of an ICS 2020/21.
A single integrated primary and community team will be developed which will ensure:
A focus on delivery of a single set of shared outcomes
A blended workforce model including social care
A focus on getting the care model right for older adults (65+) in 19/20 and for
the whole population in 20/21
High quality, accessible primary care with continuity with registered GP
Continuity of care for patients and their carers through case management
principles allocating resource around need of patients, though risk
stratification and tiering of patients
Use of Hubs, embedding a multi-disciplinary team approach and interface with
other services as part of a wider team
Proactive planned care and early escalation of risk when a patient becomes
Patient owned care plans and focus on the personalisation agenda with active
self-care supported through third sector organisations
Primary Care working at scale
In order to build resilience we will support the development of primary care networks.
This will include:
Working with the GP federation to develop a Primary Care Network
Committing to providing resources at a PCN level to give practices time,
capacity and capability to develop joint working
Support practices to ensure they have long term resilience plan in place
where necessary with a commitment to practices being part of formal PCN by
A Road map to an Integrated Care System
A single Integrated Primary and Community Team delivered at a PCN level will form
part of a partial ICS by 2020/21.
We will develop a detailed road map, with our NCL colleagues, which will build
capacity and capability to ensure that we have an outcome based approach to
integrated care with a capitated, whole person budget from 2021/22
Strategy overview: Key Milestones
May June July Aug Sept Oct Nov
Enfield Together Strategy
Our Case for Change
North Central London describes a persuasive case for change in its Strategy and
Transformation Plan published in November 2016, it defines the changing health and
care needs of local people and the key issues facing health and care services in
North Central London (NCL) and offers key areas of focus all of which are owned by
us locally or supported at scale with NCL as appropriate.
Health promotion, particularly focusing on those who are healthy and well but
are at risk of developing long term health conditions.
Early detection and management of disease and illness, especially through
more systematic management and control of long term health conditions in
The quality of primary care provision and the primary care workforce. It also
suggests a focus on reducing variation between practices. This may reduce
Emergency Department attendances, short stay admissions and first
Better integration of care for those with long-term conditions, and ensuring
that suitable and sufficient social care is available. There also needs to be a
focus on people in residential and nursing homes.
Reducing the length of stay and avoidable admissions in acute hospitals, in
partnership with social care.
The delivery of emergency services in hospitals in NCL.
Understanding the differences between hospitals in the delivery of planned
care in greater detail.
The provision of mental health services, particularly the physical health of
those with a mental illness, early diagnosis and access to integrated services.
Recruiting and retaining the workforce, particularly where there are high
vacancy and turnover rates or shortages in staff, and a focus on new roles
and developing the existing workforce through new skills and ways of working,
as well as adapting roles to changing requirements.
The cancer pathway across primary and acute providers.
Buildings that are old, expensive to run and not fit for purpose, and developing
buildings that support patient and clinical needs.
Developing system-wide governance and leadership to support the
implementation of integrated information sharing and technology.
Addressing the projected financial deficit.
Programme Teams and Governance
The key to success of this strategy is co-production with our local providers and the
wider system, with all appropriate partners inputting into the detailed development
and delivery of the programme. All programmes of work are co-developed with
service users, clinicians, Council and the voluntary sector across Enfield.
The coordination of a large amount of change activity which is taking place across
the Enfield footprint requires clinical and officer leads in place to ensure
representation from all of the key programme teams at all relevant discussion
events; these programmes will also change as we begin to deliver the new model of
care. The current CCG programme teams in place are:
Programme GB Clinical Lead CCG SRO
Overall Enfield Together Dr Mo Abedi John Wardell
Urgent and Emergency Care Dr Fahim Chowdhury Graham MacDougall
Planned Care Dr Elizabeth Babatunde Vince McCabe
CHC Richard Pearson
Medicines Management Dr Chitra Sankaran Deborah McBeal
Primary & Community Out of Deborah McBeal
Enfield CCG 2019/20: Chair of Steering Group: Programme Manager
Governance Frequency: Weekly
Purpose: Project Managers to discuss progress and raise
Programme delivery issues
Group Chair Programme Board: Programme Director
Programme Purpose: Gain assurance that projects are delivering to plan.
Board Agree with Programme Lead the project progress, mitigations
& support needed.
Planning Chair of Business Planning Meeting: Chief Operating Officer
Meeting Frequency: Weekly
Purpose: Sub-group of TPG, the programme drives delivery
ECCG TPB of the Recovery Plan & supports achievement of all
programmes, both financial/non-financial.
F&P Chair of ECCG Transformational Programme Board: Chair
Committee Frequency: Weekly
Purpose: Sub-group of F&P, TPG provides assurance,
ECCG performance monitoring & advice for projects & programmes
Governing reporting as part of the Recovery programme
Chair of F&P Committee: ECCG Chair
Purpose: Review & understand CCG performance against its
financial duties & the major financial risks facing the CCG; and
authorise investments & business cases.
Chair of ECCG Governing Body Meeting: ECCG Chair 10
Purpose: Ensure the CCG functions effectively & efficiently;
decisions and changes to local health services are debated &
made openly and fairly; and oversee the CCG’s work.
Outcomes: Focusing on Quality
Enfield Together Logic Model
Resources/Inputs Activities Outputs Outcomes
In order to deliver the purpose of In order to address the problem the We expect that once accomplished, We expect that if accomplished,
the strategy we invested the strategy requires the following activities: these activities will produce the these activities will lead to these
following: following outputs: changes:
Staff resource (CCG; assessment using population Single integrated Population Health
provider, STP, health analytics & deep dive community team Proactive care to
ICHP/AHSN; other into case files of complex maintain good health
external expertise where patients Single management
required) structure Diseases well managed
Developing a workforce model
Clinical Leadership based on care functions Single care record Care tailored to local
identified through needs supported by integrated need
Infrastructure, hardware analysis to make digital/IT functionality
or software recommendations around Patient Experience
staffing roles, responsibilities Single assessment of Living independently at
Financial Investment and skills mix health and care home but not isolated
Best practice from Refining the model of care Single set of incentives Having one conversation
national and (increased care functions;
international integrated whole population; increased (outcomes-based KPIs)
care models with efficiency of effort and
transferable insights outcomes delivery) and standards Reduced health
Business Case and inefficiencies
developments to deliver ‘Integrator’ function set up
shorter (19/20) and longer
(20/21 onwards) term to drive integrated care Financial Benefits
Provider and patient
engagement and co-production Single capitated budget duplication by identifying
Development and increased (virtual/shadow in 20/21; and removing Nursing,
visibility of an Integrated ‘live’ in 20/22) care duplication and
Partnership Board – including
review of membership identifying opportunities
OD around Primary Care Primary Care Networks to use resources better
Networks (driven by Primary
Care) defining needs
Continuous monitoring and assessment of their local Improved value by
action learning to drive iterative
improvement/ enhancement. populations enhancing the cost
effectiveness and quality
Realistic financial plan with of interventions
phased delivery of benefits
Workforce plan, which Staff acting as one
provides a career organisation with shared
trajectory for all staff, to values (including
improve staff retention and voluntary sector, wider
satisfaction. community assets
available to staff and
readily shared when
ASSUMPTIONS Working as a single
Collaboration between commissioners & providers with strong clinical team with carers
Staff recruited to populate workforce plan & meet skill mix requirements EXTERNAL FACTORS
of the iteratively developing model of care.
Building on the strong foundation of current services to develop the out of Engagement with acute providers to ensure vertical integration with
hospital care model functions, in order to drive shorter-term financial the out of hospital pathways.
NCL STP strategy will have an impact on elements of the local
system’s planning and close collaboration is required between NCL
and other CCGs to ensure plans are aligned and planning resources
are used efficiently.
Outcomes: Population Health (wider determinants of health)
The health of a population is influenced by a wide range of factors and the
interactions between them. They include the local environment – such as the
conditions in which people live and work; social and economic factors – like
education, income and employment; lifestyles – including what people eat and drink,
whether they smoke, and how much physical activity they do; and access to health
care and other public and private services. Age, sex and genes make a difference to
health too, as well as social networks and the wider society in which people live.
Improving population health depends on collective action with different services,
sectors, and community groups – including the ‘assets’ found in local communities
(like people’s time and skills, social networks and physical spaces like schools).
Enfield Together will create time and space for the system to collectively understand
what factors are influencing the health and well-being of their population and put in
appropriate measures to support people to manage their own care or access the
care they need to stay living well at home.
Acute Care: Admission prevention
Plans to reduce admissions include:
Demand management schemes to reduce GP elective referrals
Decommissioning of low or no value acute services
Ambulatory Care to ‘diagnose to admit’ rather than ‘admit to diagnose’
Community consultant access from care packages/MDTs and shifting acute
Care packages focussed on self-care, management and prevention as per
local health need
Integrated care to focus on crisis prevention, early intervention and condition
Best care packages and plans for management of long term conditions
Tighter integration across primary care/acute for long term conditions and
closer integration of community health services and social services
Targeting excess bed day numbers and reducing lengths of stay
Reducing the ratio of first to follow-up outpatient procedures
Child health services hub incorporating an ambulatory care service, urgent
care services and a paediatric assessment unit
Facilities for primary care and the care of children with complex needs/long
conditions in a community-based hub
Multi-disciplinary teams of health professionals (including community teams)
working across traditional care settings and boundaries
Urgent Treatment Centre
Urgent Care streaming (patients streamed to community option or self-care if
Four walk in centres across Enfield
GP extended hours
Planned Care: Long Term Conditions
The NHS Long term plan has identified key areas for us to focus on over the next 5-
10 years. We already know that in Enfield cancer, diabetes, cardiovascular disease
and stroke results in 50% of all deaths; respiratory disease is often linked with
cardiovascular disease so we have the full backing of the NHS long Term plan to
help tackle these disease groups and makes up the planned care programme of
work for year one 2019/20.
The correlation between elective and emergency care often becomes blurred when
we start to explore how we deliver the new models of care; the solution is the same.
Integrated community teams (led by primary care) that have access to specialist
support, co-ordinating care using a single detailed care plan, wrapped around the
patient to keep them well at home for as long as possible. If they do become acutely
unwell the same team gets them home as quickly as possible ensuring they have the
right levels of care to support them to recover to the best level they can.
It is important to note that cancer has now been designated a long term condition
with patients living with and surviving cancer for many years. This can often be a
traumatic and difficult journey which requires sensitivity, linking with Mental Health
IAPT services specifically for long term condition support is a key component of
supporting people with one or more long term condition.
Over the next three years we will see a right sizing of the acute hospitals and an
expansion of our community care, self-referral and triage by specialists will help the
system to identify and manage care within the community only utilising acute care
when someone is acutely unwell.
We will also develop more seamless end to end pathways for those planned care
treatments that are defined as single episodes of care, where once treatment is
completed you are discharged from care e.g. Hip replacement or cataract surgery.
We will explore the hand offs between various stages, identifying potential
inefficiencies and variation across inpatient and outpatient activity, creating pathways
that deliver the right care by the right clinician first time.
Mental Health: Peppa A
CHC: Richard P
Integrated Community Team: Graham/Philippa
Workforce: NHS Long Term Plan/Workforce Implementation Plan John P/CEPN
Workforce: Emerging competency framework for Integrated Community Team
As we move towards a single integrated health and social care team the need for a
comprehensive competency framework, that covers all health and social care
professional staff and which enables staff to fulfil their potential and provides a
structure for career progression, becomes more apparent.
It is envisaged that all staff should be trained to provide as many core skills to
patients to reduce duplication of effort As we move towards a single integrated health
and social care team the need for a comprehensive competency framework, that covers all
health and social care professional staff and which enables staff to fulfil their potential and
provides a structure for career progression, becomes more apparent.
It is envisaged that all staff should be trained to provide as many core skills to
patients to reduce duplication of effort where possible. Opportunities should be given
to staff to add to existing professional skills with the right clinical and regulatory
support. All staff should be encouraged to work to the top of their licence.
To do this we will need to:
Scope, review and benchmark against all existing competency frameworks;
working across partner organisations to pull together a whole community
Reviewing existing complementary training modules and courses (Bucks
University - Innovations in Health Programme) (Free modules to build
CPPD)(Integrated learning – King’s University)
Co-design career pathways for staff and facilitate better staff retention
Complete a workforce skills and task map and develop a systemised
Share knowledge and training plans with other agencies / CCGs
Establish a mandatory framework
Establish a baseline to provide an overview of the current staff training
situation for all staff and training required
Develop inter-agency career opportunities and career pathways for new
Identify shared baseline training and specialist training where possible.
Estates and Hubs – John P/Richard
• CC2H premises Task and Finish Group next meeting 24th April 2019;
• Review of estates impact with PCN applications from 15th May 2019 onwards;
• Update of the local estates strategy during April/May 2019
• Ongoing technical support and facilitation to the development of local practice
premises to offer more patient service capacity throughout 2019;
• Project plan to be developed that describes the tasks that need to be
undertaken in the next 1-3 years in line with integrated, place-based
community teams – use of void space
• Hub development?
Digital – John P/Peter Lathlean
NHS Long term plan - over the next five years every patient will get the right to
telephone or online consultations, usually with their own practice, with the emphasis
on digital access. For outpatients, technology will be used to redesign services to
avoid up to a third of outpatient visits
All the pieces for Enfield Together
DETAILED PLANS FOR 2019/20