Read the text of this document (107 pages)
Joint Forward Plan for
North West London
Draft, July 2024
July draft for Health and Wellbeing Boards
DRAFT
July draft for Health and Wellbeing Boards
Section 3: Our Enabling teams 73
Our digital and data strategy 74
Our ICS workforce plan 76
Our estates strategy 77
Our communications and involvement priorities 79
Section 4: Our Provider Collaboratives 80
Our Provider Collaboratives 81
Section 5: Our Borough Based Partnerships 83
Our Borough Based Partnerships 84
Bi-Borough of Westminster, Kensington and Chelsea 85
Brent 87
Ealing 89
Hammersmith and Fulham 91
Harrow 93
Hillingdon 95
Hounslow 97
Section 6: Supporting plans 99
Our commitment to quality, safeguarding and infection prevention and control 100
Meeting the legislative requirements of the Joint Forward Plan 102
Section 7: Glossary of key terms and acronyms 103
Contents
Foreword 2
Section 1: Introduction 3
Who we are – our system and population 4
How we collaborate with our people and our communities 5
The health and care needs of our residents and communities 6
Our financial challenge 7
Our productivity challenge 9
Components of an integrated care system 11
Our organisational challenge 12
What we promised in our Health and Care strategy 13
How we have reflected the Health and Care strategy in our Joint Forward Plan 14
Section 2: Our Priorities for North West London 15
Our priorities over the next five years 16
How we will align our priorities during the period of the plan with our medium-term
financial aims
17
PRIORITY 1: Improve health outcomes through Population Health Management 18
PRIORITY 2: Improve Children and Young People’s Mental Health and Community Care 24
PRIORITY 3: Establish Integrated Neighbourhood T eams (INT s) 30
PRIORITY 4: Improve mental health services in the community and for people in crisis 36
PRIORITY 5: Embed the core community offer and maximise productivity 42
PRIORITY 6: Optimise patient flow across the system – right care, right place 48
PRIORITY 7: Transform maternity care 54
PRIORITY 8: Increase cancer detection rates and deliver faster access to treatment 60
PRIORITY 9: Transform the way planned care works 66
1
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Rob Hurd
Chief Executive Officer, NHS
North West London ICB
Penny Dash
Chair of NHS North West
London ICB
We are delighted to introduce our five-year Joint Forward Plan (JFP).
The plan builds on the Health and Care Strategy we published last year, which
sets out how North West London’s eight local authorities and the local NHS will
improve outcomes in population health and wellbeing, prevent ill health and
tackle inequalities, enhance productivity and value for money and support
broader economic and social development.
The JFP is technically joint between North West London Integrated Care Board
and our partner NHS trusts, and sets out how the local NHS will prioritise,
sequence and deliver measurable improvements and outlines what we will do to
deliver our strategy and when. It complements the Joint Health and Wellbeing
Strategies developed by each of our boroughs.
The past few years have been incredibly challenging for everybody working in the
NHS, with the COVID pandemic, rising waiting lists and industrial action. Although
NW London is one of the highest performing integrated care systems in the
country, these challenges have not passed us by and feedback from our
residents is quite clear that we can do more.
So the focus of the next two years has to be on transforming our health and
care services so that they continue to respond to the needs of our residents and
communities.
For the next two years we will prioritise reducing waiting times and improving
productivity to provide access to a common set of high quality services
regardless of where our residents live. We will, for example, test proactive
approaches that prevent, reduce or delay the onset of need; support our
residents to stay well; and identify and support people at risk of, or diagnosed
with, illness by providing best practice interventions.
T o deliver the plan, we will continue to work with local authorities, primary care,
the voluntary sector and our communities across North West London to
coproduce and develop services that meet our communities’ needs and that
they can have confidence in. Our aim is to be ready to roll out these
programmes over time, within the context of a resilient, efficient and effective
NHS.
Delivering this Joint Forward Plan will require building on the shift to working as
a system we saw during the pandemic. It means working across sectors to
foster an environment which supports healthy behaviours and lifestyles. With
the commitment, expertise and resources of our partners across our
collaboratives and borough-based partnerships, we are confident that we can
deliver on our ambition.
Foreword
2
Section 1: Introduction
DRAFT
July draft for Health and Wellbeing Boards
Who we are – our system and population
Welcome to the Joint Forward Plan
for North West London. This plan
sets out how the NHS will support
the delivery of North West London’s
Health and Care Strategy, published
in 2023.
North West London is one of the
biggest and most complex
Integrated Care Systems nationally.
We have a diverse population of
over two million people, who come
from over 200 different ethnicities.
While in general our residents are
more affluent than the national
average, we also have significant
clusters of multiple deprivation and
concentrations of groups we
struggle to hear. These include
asylum seekers, travellers and
members of particular ethnic groups.
North West London by numbers
1,500 adult social care staff 1,500 voluntary organisations
1,300 GPs 349 GP practices276 care homes
4 acute trusts
8 Boroughs2.1m resident population 65,000 NHS employees
Our population is:
• Younger than elsewhere in England. The median age across our boroughs ranges
from 35 to 39 with the median age across Integrated Care Boards in England
averaging 40.
• One of the fastest growing. Population projections are uncertain due to the ongoing
impact of factors like immigration, COVID-19 and Brexit, but an increase of over
100,000 by 2040 is predicted.
• More diverse, with our residents speaking well over 60 different languages. Brent,
Harrow, Ealing, Hounslow and Hillingdon all have a higher share of non-white
population than the London average. After ‘white ethnicity’ the largest ethnic
population is ‘Asian/Asian British’.
• More affluent than the national average, but with pockets of significant
deprivation. Kensington and Chelsea and Westminster have the highest gross
disposable income in North West London and nationally, however we also have
significant clusters of residents experiencing deprivation in each of our boroughs.
• Has a higher life expectancy than the national average, but with a difference in life
expectancy between our most affluent and most deprived neighbourhoods of almost
two decades.
• Has higher unemployment rates and rates of people economically inactive than
the national average, and this is higher still in our most deprived populations
1 ambulance trust 4 community and mental health trusts
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How we collaborate with our people and our communities
How we engage with our residents and communities?
Working alongside our residents and communities is critical to delivering excellent and
equitable health services for our population. T o ensure wide reaching involvement, our
‘What Matters to You’ programme engages in a range of ways:
• Our community outreach programme reaches up to 60 community groups across
NW London each month, going into communities and asking what matters to them as
well as raising specific questions about NHS services and proposed service changes.
Most of our work is targeted to specific communities to ensure we are reaching as
many people as possible.
• Community representatives from some of the most deprived and marginalised
communities in NW London make up our Co-design Advisory Body (DAB). DAB
plays a vital role in shaping the collaborative approach, ensuring that community
voices and insights are central to the decision-making process. Each participant
represents one community group.
• Our Citizens’ Panel is a large group of local residents, randomly selected from
people across our 8 boroughs. Some targeted recruitment took place to ensure that
the panel is representative. The number of members is around 4,000 and it is used
for surveys and interactive online engagement.
• We hold regular North West London Residents’ Forums on specific topics and most
borough-based partnerships hold regular forums for residents. There is an
independent Patient Participation Group Forum which we support.
• We use a range of social media to engage with our residents and communities: Next
Door, Twitter, Facebook, Instagram.
• Our Integrated Care Board and Integrated Care Partnership meet in public, with the
public invited to ask questions at both meetings.
• Feedback and questions to the ICB can be submitted via our dedicated email
address nhsnwl.communications.nwl@nhs.net
How we work with our voluntary partners
We are committed to help residents and our frontline staff
to get the very best out of our health and care services.
Case study: Compassionate Hillingdon
Compassionate Hillingdon, funded through the Hillingdon
Health Care Partnership, is a friendship programme that
supports residents who have a life limiting condition, are
approaching end of life or long-term health condition.
The programme currently supports 208 people, with a
volunteer group of 36. We offer in person visits and
telephone calls, with a focus on friendship, as well as a
monthly coffee morning, with visiting speakers.
This service makes a difference – A Compassionate
Hillingdon Volunteer was asked to speak at a funeral by a
family because of the difference they had made.
5
Our voluntary partners are key in supporting this. Within NW London a group of like-
minded charities have joined together to support & develop health and statutory services
– called 3ST , Third Sector Together.
Their mission is to combine our specialist skills and knowledge to ensure residents have
equal access to services and to improve the health and wellbeing of all residents of the
eight boroughs of NW London.
3ST are supporting us to develop the voluntary and community sector as a strategic
partner and helping to drive closer links with our communities. Examples of work where
they are supporting the NHS include: reducing health inequalities, engaging with patients
and residents and supporting strategy and policy developments.
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The health and care needs of our residents and communities
What our residents tell us
NHS North West London, in partnership with local authorities and NHS provider trusts in
our area, has an extensive outreach programme to hear from local residents and
communities. This includes discussions in all eight boroughs, some on specific topics,
conversations via organised public events and social media, and insights collected
through our borough HealthWatches.
Every month, we publish a summary of what local people have told us in our community
insight reports. These insights inform and shape our thinking on health and care
services across North West London.
Consistent themes from residents include:
• Difficulty in securing timely access to primary care/GPs
• Confidence in mental health services, especially waiting times and inpatient capacity
• Hospital discharge, waiting times and cancellations
• Poor communication: a range of issues including complexity/clarity, language barriers
and communication with people with learning and physical disabilities
• Barriers to accessing dental care – its cost and its availability through the NHS
• Appreciation of the potential digital healthcare offers, and concern over its potential
for excluding those who most need it
• Cost of living concerns
• Potential for improving community engagement and the need to be more inclusive of
communities furthest from decision-making
• Requests for more information on specific health concerns, such as cancer
awareness, diabetes, mental health care services, and vaccinations
What our needs assessments across North West London tell us
• Progress in improving health has slowed, particularly in the past few years, and
overall healthy life expectancy has probably declined.
• While North West London’s population is generally younger than England as a
whole, the share of the elderly is growing fastest. Our residents also tend to move
more often.
• Local and national tragedies such as the COVID-19 pandemic and the Grenfell
T ower fire have exacerbated long standing inequalities in health and care.
• Across all of our boroughs, cancers, circulatory diseases, and respiratory
diseases are the leading cause of death. Ischaemic heart disease, followed by
dementia and COVID-19, was the leading cause of death in 2022.
• Preventable mortality, such as those dying before their 75th birthday from diseases
such as lung cancer, differs hugely between different areas in North West London.
Some of our communities experience much higher death rates from diseases which
can be effectively prevented.
• Various demographic groups face health inequalities, including those of
different ethnicities and socioeconomic backgrounds, as well as individuals with
autism or learning difficulties.
• While progress has been made, stigma persists, particularly in mental health
among certain of our communities, and there's a call for more focus on prevention
and healthy living.
• The rise in the cost of living has challenged many, while the gap between our
communities in income, economic inactivity and unemployment has widened over
the last five years.
• Despite efforts to improve, access to healthcare services remains inconsistent, with
variations in delivery and quality across different areas.
More detail on health and care need, and insights from our communities, can be found on our website: https://www.nwlondonicb.nhs.uk/
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NW London Integrated Care Board receives a direct
allocation of £5.3 billion. This includes spend on primary
care – including dentistry, ophthalmology and
pharmacy, but excludes specialised services
commissioned by NHS England. This represents 4% of
the national allocation to integrated care boards, and is
the fifth largest nationally. The allocation is based on a
formula which reflects a range of factors including
demography, morbidity, deprivation, and the
unavoidable cost of providing services in different areas.
The formula gives North West London the sixth lowest
target allocation in the country, and our actual allocation
is in line with this target. This means that our allocation
is 3% lower per needs weighted head of population than
the national average.
Our financial challenge (i)
£2,674m
Acute
£839m
Primary Care
(including delegated
commissioning)
£556m
Mental Health
£444m
Community
£311m
Continuing
healthcare and
discharge to assess
£240m
Dental, optometry
and pharmacy
£57m
Programmes £37m
Running Costs
£86m
Reserves
ICB planned spend
for 2024/25
£1,887
Year
Vs
£1,946
National average
7
Compounding the issue of the in year financial
allocation, the outlook for the NHS’ finances also
appears challenging. The population of North West
London, in common with almost all areas of England,
continues to age. The Office of Budgetary
Responsibility's latest fiscal risks report increased the
risk of demand and cost pressures in health
materialising. This suggests that pressures on health
budgets – including the ICB’s – are likely to be
sustained.
Updated planned spend
numbers
Added bottom left para
in response to LA
feedback
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Our capital challenge
The NHS in North West London has some of the most challenged infrastructure in the
country with a backlog of maintenance work at a cost of £1.2bn. This is more than
three times the size of some other ICBs.
Ensuring that the estate remains available for use puts significant pressure on both
revenue and capital budgets, whilst driving capacity issues and poor patient
experience. The capital available to us to improve our estate is insufficient; we
continue to push for capital support for major investments, such as the rebuilding of
our four hospitals in the New Hospitals Programme.
T o prioritise how and where we invest our money, we have brought together all NHS
and local authority stakeholders within each borough to plan health and social care.
This includes placing primary care services where the population requires it,
improving utilisation of space and, wherever possible, bringing together services that
improve user experience into fewer, higher quality buildings.
Our financial challenge (ii)
Fairer financial allocations
While progress has been made, allocations within North West London are still largely
based on decisions made by our predecessor clinical commissioning groups. Our aim
is to ensure that resources and funding are allocated based on the needs of our
residents. In 2023/24, North West London ICB spent more on acute care (3%),
community care (9%) and continuing healthcare (9%) than need would suggest we
should, and less in mental health (20%).
Over a period of three years we aim to move our expenditure allocation in line with
need and will address this by:
• Ensuring all expenditure is consistently captured;
• Managing growth into those overfunded areas and increasing services
commissioned in underfunded areas; and
• Commissioning services in line with the core North West London standard,
eliminating duplication in services and ensuring that the correct care is provided in
the most appropriate setting at the required level of productivity.
Given the low likelihood of significant growth in allocation, the bulk of this shift in
allocation will need to be funded by changing models of care and improving
productivity.
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Our productivity challenge
The NHS is experiencing unprecedented pressures,– struggling to
balance being financially sustainable whilst tackling significant
waiting lists and long A&E waits as our residents age, and the acuity
and complexity of their needs increase. Although North West
London is typically one of the better performing systems in the
country, this position is also true for us.
While money and staff have increased substantially in the last two
years, productivity and efficiency have not yet recovered to pre-
pandemic levels and therefore remains a critical focus for us all. It is
improving productivity that will free up the funds for investing in
better, more equitable services for our residents and communities.
Like all parts of the country, the NHS in North West London faces a
challenging position. T o date, we have been able to use one off
savings to ensure our expenditure matches income, but this is not
sustainable in the longer term. Delivering a sustainable financial
position by the 2026/27 financial year would require a 3.7%
improvement in efficiency over and above normal productivity gain in
each of the next three years.
Productivity is not about telling already pressed staff to work even
harder. It is about changing how we work, as the examples on the
next page illustrate:
• It is about how each of organisations work smarter - for example,
using technology to perform routine tasks better, or to improve
scheduling and minimise waste and rework;
• It is about addressing our residents’ need in the least intensive
setting appropriate – for example, supporting more self-care,
supporting more prevention, or establishing digital options where
these improve access, quality and/ or equity at lower cost
• It is about seeking to promote wellness and actively manage
illness, rather than reacting to people becoming acutely unwell
Each of four levels - organisation, collaborative, place and system -
has a role in bringing the system back to balance by improving
productivity as laid out opposite.
• Recover and increase
productivity to pre-
pandemic levels
• Address patient
waiting lists
• Improve utilisation of
space
• Treat patients in
lowest acuity setting
appropriate
• Reduce number of
physical beds open
• Better use of the Better
Care Fund, develop
additional capacity /
winter funding, place-
based innovation to
increase productivity
and improve flow
• Improve data capture to
inform planning
• Deliver shift to lowest
acuity settings where
clinically appropriate
• Flow and average length of
stay, reduce over prescribing &
over treating,
• Review payment mechanism
and local prices
• Service developments to
replace Mental Health
Investment Standard
• New workforce roles and
Additional Roles
Reimbursement Scheme
(ARSS) productivity
• Standardise core offer
• Embed population health data
and consistent evaluation
• Align commissioning to
financial recovery
• Sector led change
programmes to improve
access and address unmet
need
• Evaluate & consolidate non-
clinical services
• Enable shift to lowest acuity
setting (acute to community)
where clinically appropriate
System
roles in
improving
productivity
Trust Collaborative
SystemPlace
9
Expanded definition of
productivity to include
the left shift, in
response to LA
feedback
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Our productivity challenge: Case studies
Case study: Improving flow through the autism diagnostic pathway - Community Paediatrics
The Community Paediatrics Service was struggling to cope with increased referrals and had received complaints from parents that children had to wait too long following their first
appointment for assessment and diagnosis. The multidisciplinary team used quality improvement methodology to identify and test changes to the clinical pathway to reduce wait
times. This resulted in:
• A reduction in time from assessment to diagnosis for children under 11 from an average of 25 weeks to 3 weeks.
• T ested new pathway for children over 11 years which has reduced journey time from referral to diagnosis from an average of 82 weeks to an average of 48 weeks.
• Improved staff morale, despite rising workload and ongoing challenges
• Encouraged a culture of improvement and learning across the department.
Case Study: National Wound care strategy
Community services in Goodall, hosted by Central North West London Community Services (CNWL) is an early implementer site for the national wound care strategy. We have
focused on more consistent, and improved pathways which has resulted in wounds being healed quicker, but also not having recurring wounds which has reduced pressures on a
range of services that include district nursing, complex wound care but also primary care services and acute hospitals. Patient experience has also improved.
Healing rates at 24 weeks have improved from 14% in April 2023 to 57% in December 2023 for venous leg ulcers.
There is now greater awareness across the system to identify and support wound care earlier, the new pathways support a preventative rather than reactive approach, and there is
increased capability and confidence across all the teams to support patients with wounds.
Case study: North West London Elective Orthopaedic Centre (EOC)
In autumn 2023, the APC opened a centre of excellence for planned orthopaedic care at Central Middlesex Hospital. The EOC will deliver productivity and quality of care for patients
that consistently meets best practice and delivers value for money. It supports productivity through dedicated facilities, staff and economies of scale which together embed best
practice pathways, support efficient scheduling and effective outcomes.
The EOC opened 3 theatres in December 2023 and 5 theatres in April 2024, achieving so far:
• An average length of stay of 2.8 days in the first 10 weeks of operation, already almost reaching the Y2 target of 2.3 days
• Productivity benefits of £545k FYE in 2023/24
• 100% patient satisfaction
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Providers
The way health and care is organised has fundamentally shifted in the last years
Integrated Care Board
Integrated Care Partnership
NHS acute trusts –
supported by the community
collaborative
Primary care – general
practice, pharmacy,
optometry
Social care providersVoluntary sectorOther providers
Academic
partners
Healthwatch
Integrated Care System
Sets strategy, aligns the ambitions, purpose and strategies of partners across the system.
Integrated care systems (ICSs) are geographically based partnerships that bring together providers and commissioners of NHS services with local authorities and other
local partners to plan, co-ordinate and commission health and care services. They are part of a fundamental shift in the way the health and care system is organised –
away from competition and organisational autonomy and towards collaboration.
Develops plans, allocates (NHS) funds and
arranges for the provision of health services
Establishes joint working arrangements
Leads system wide action on people plan, data and
digital
NHS mental health trusts –
supported by the Mental Health
collaborative
NHS community trusts –
supported by the community
collaborative
Secures care (NHS) Secures care (Public health, social care)
Local authorities
Arranges provision of social care and public
health services.
Responsible for other vital services that
contribute to health and wellbeing such as
housing, education, leisure and transport.
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Our organisational challenge
12
Our nascent provider collaboratives are establishing resilience
North West London currently has three provider collaboratives - acute care, mental health
and community care. The collaboratives provide a great opportunity to capture the benefits
of scale, reduce unnecessary variation and create greater resilience within our system and
their role will grow and evolve over the period of this plan.
We continue to build relationships with our Local Authorities
Improving health and care for our residents and communities requires close working with
our eight local authorities – including their children's, adult social services and public
health teams - to address the needs of our residents. Our borough based partnerships are
the vehicle for achieving this by working differently and more effectively with local
authorities to share resources and expertise across the system.
Our Integrated Care System is still new, and managing a series of
changes
The Health and Care Act 2022 led to significant changes in how the NHS operates.
This included establishing Integrated Care Boards with new statutory responsibilities
(in place of Clinical Commissioning Groups), and the furthering of partnerships
between trusts, otherwise known as provider collaboratives. As a system across
North West London, including our local authority and voluntary sector colleagues, we
continue to work through the implications of these changes so we can continue to
deliver the changes our residents need.
We are restructuring our workforce
In addition to the new responsibilities, the Integrated Care Board is required to reduce
its internal administration (running) costs by 30% by 2025/26. The Integrated Care
Board is therefore restructuring its teams to match skills more closely to expectations
and duties with fewer staff. Over 2024/25 we will need to spend significant time
embedding this change and developing ways of working within the resource
available, This includes some of our largest areas of spend such as continuing
healthcare.
We are continuing to develop our values and operating model
Our ways of working – known as our operating model - have been agreed with
partners across North West London. The model has our borough based partnerships
at its core, supported by our ICS programmes and other ICB teams. Working
collectively will help us to simplify across our 8 boroughs. The ICB’s values stress
empowered communities, always being inclusive, growing together, driving
innovation and being mutually accountable, and will support us to increase our
effectiveness and productivity. However, as we continue to develop, we will need to
update the model so we continue to improve how we deliver our objectives.
What does this mean for our Joint Forward Plan?
The Integrated Care Board has established an organisational design programme to
improve how the ICB can deliver its objectives more effectively. This includes:.
• Identifying and building the right capacity, capability and culture;
• Changing the way we work to clearly define roles, responsibilities and expectations of
different parts of the system – for example aligning commissioning with local authorities;
• Redesigning our organisation to ensure functions, structures and governance enable
the right conditions to deliver our objectives;
• Revamping our processes to enable our staff to work as slickly as possible; and
• Building and embedding ways of evaluating the effectiveness of all of our work.
As part of this, this Joint Forward Plan prioritises and phases the implementation of
objectives over a period of five years, committing to doing the right number of things well
and tracking progress effectively rather than attempting everything at once.
It also means that this plan will be updated annually as the operating model develops and
the change programmes across partners in North West London deliver and evolve.
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What we promised in our Health and Care strategy
The health and care system in North West London aims to:
Support
population
health and
well-being.
North West London aims to address wider determinants of health by partnering to
improve access to education and employment, utilising NHS land for housing,
ensuring fair wages, boosting digital skills, supporting local businesses, and
promoting sustainability efforts.
Regarding healthy behaviors, we plan to collaborate with public health partners to
reduce smoking rates, improve diet and exercise, identify and treat residents at
risk of high blood pressure, and increase uptake of preventative services through
cross-sector collaboration and lessons from the COVID-19 vaccination
programme.
Address
inequalities
in health
outcomes,
access, and
experience.
We aim to address health inequalities through several initiatives. This includes
developing a unified approach for residents regardless of location, ensuring
consistent quality of care, understanding population health data, supporting unpaid
carers and addressing structural racism in healthcare.
Improving access and outcomes for vulnerable groups like the homeless and
asylum seekers, enhancing early cancer diagnosis and long-term condition
management, combating mental health stigma. Providing tailored support for
specific communities such as black women and those with learning disabilities or
autism is also a key priority.
Improve
access to
care.
Efforts will focus on improving access to primary care by effectively organising and
managing access to urgent care, embracing digital technology for triage and
appointments, and implementing integrated neighbourhood teams, with general
practice at their heart, to coordinate community physical and mental health
services.
Additionally, investments in expanding capacity for mental health, learning
disabilities, and autism services are a focus, along with improving access to
specialist expertise and diagnosis through integrated teams and digital tools.
Prioritize the
health and
well-being of
babies,
children, and
young people.
We will invest more in supporting babies, children and young people to be happy
healthy adults, by addressing obesity, promoting healthy weight in early
childhood, increasing breastfeeding rates, and improving immunisation uptake
and oral health.
Efforts also aim to enhance access to mental health support, especially through
schools and digital platforms, and to develop consistent models of care through
child health and family hubs.
Promote
home-based
care when
possible.
While hospitals and care homes may be the right place for some of our
residents, for many we can provide a better service with less disruption to
people’s lives by bringing expertise and support to people’s homes.
T o do this we will implement joint care planning across all health and care
settings, give personalised support for long-term conditions, and proactive care
planning for end-of-life care. Collaboration with social care partnerships with
voluntary providers aims to prevent hospital and care home admissions, while
ambulatory care services will be provided in GP practices and urgent care
centres.
Enhance the
productivity
and quality of
the health and
care system,
collaborating
with residents
and
communities.
We know that the resources available to providers of health and care are limited
and funding available for social care and public health has constrained. While
the number of health and care staff have risen, we face difficulties in recruitment
and retention.
We must therefore continue to innovate, improve and deliver as effective care as
we can within the budget available to us while valuing and developing our
people.
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How we have reflected the Health and Care strategy in our Joint Forward Plan
In November 2023 we published our Health and
Care strategy for North West London, with six
key areas of focus.
The Joint Forward Plan takes the strategy, the
nationally set NHS operating plan and agreed
national and local targets together, and
translates them into meaningful milestones and
activities. This clarifies where the NHS will
prioritise resources and objectives now and
where we should invest in the future. We have
focussed on nine specific priorities, supported by
a number of enabling programmes, to deliver this
Joint Forward Plan.
Our Joint Forward Plan sets out the time period
for delivering these priorities and intended
outcomes.
Delivery will require cross-system collaboration
from our providers through provider
collaboratives, ICS programme teams, clinical
networks, voluntary and community sector
organisations (VCSEs) and borough teams.
Our borough based partnerships and provider
collaboratives will continue to have their own
specific plans to improve health and wellbeing
and to deliver the operating plan. However,
aligning these with the Joint Forward Plan will
mean that we can concentrate resources across
the system in the most effective way possible.
Which formed our nine priorities
Our enabling programmes are vital
in supporting all of our priorities
Hillingdon
Ealing
HounslowHammersmith
& Fulham
HarrowBrent
Westminster
Kensington
& Chelsea
With locally-specific support
driven through our Boroughs
WORKFORCE ESTATESDIGITAL
& DATA
Financial considerations Our annual NHS operating plan
COMMUNICATIONS
& INVOLVEMENT
NHS partners across North
West London are committed
to reviewing and updating this
Joint Forward Plan each year.
This will enable us to respond
to future pressures and
changing population need. In
2024/25, we will agree
strategies for Digital and
Data, Estates, Urgent and
Emergency Care, Maternity
and Mental Health Learning
Disabilities and Autism. Our
Acute Provider
Collaborative will also
publish a strategy covering
Planned Care.
Once agreed, these
strategies will be incorporated
into next year’s plan
Support
population
health and well-
being.
Address
inequalities in
health
outcomes,
access, and
experience
Improve access
to care.
Promote home-
based care
when possible.
Prioritize the
health and well-
being of babies,
children, and
young people.
Enhance the
productivity and
quality of the
health and care
system,
collaborating with
residents and
communities.
We published our Health and Care strategy in November 2023
14
Section 2: Our priorities for North West London
DRAFT
July draft for Health and Wellbeing Boards
PRIORITY 1: Reduce inequalities and improve health
outcomes through population health management
Develop and embed a population health management capability and focus on areas where outcomes, access
and experience vary most to reduce inequalities and improve health and wellbeing
PRIORITY 2: Improve children and young people’s mental health
and community care
Improve health and wellbeing outcomes for children and young people, including targeted interventions for our
core at risk groups
PRIORITY 3: Establish Integrated Neighbourhood T eams (INT s)
with general practice at their heart
Establish INT s with primary care at their heart to improve same day access to care for those who need it and
provide proactive joined-up care for people with long term conditions or complex needs
PRIORITY 4: Improve mental health services in the
community and for people in crisis
Maximise the productivity of community-based mental health services and increase access to mental health
crisis services
PRIORITY 5: Embed access to a consistent, high quality set of
community services by maximising productivity
Implement a common core offer in community services (initial focus on community nursing, community beds and
neuro rehab) and then drive increased productivity across these services.
PRIORITY 6: Optimise ease of movement for patients across the
system throughout their care – right care, right place
Deliver improvements across the system to ensure patients are treated in the most appropriate setting –
avoiding admission, minimising hospital stays and supporting timely discharge
PRIORITY 7: Transform maternity care Improve maternity services to reduce inequalities in outcomes and improve quality for all
PRIORITY 8: Increase cancer detection rates and deliver
faster access to treatment
Improve early diagnosis by tackling variation in screening and deliver faster and more efficient access to
diagnosis and treatment.
PRIORITY 9: Transform the way planned care works Transform planned care to reduce waiting times for diagnostics, outpatients and elective surgery and manage
rise in demand for hospital services so patients can be seen in the most appropriate setting
What are North West London’s priorities over the next five years?
We have collectively identified nine priorities for the NHS across North West London to focus on over the five years period covered by this Joint Forward Plan. These priorities
will benefit from a system-wide approach. Our collaboratives and enabling teams will support these priorities, while our borough based partnerships will supplement these with
local priorities where there is specific local need.
Our enabling programmes are vital
in supporting all of our priorities: WORKFORCE ESTATESDIGITAL & DATA COMMUNICATIONS
& INVOLVEMENT
16
DRAFT
July draft for Health and Wellbeing Boards
Our priorities build on and incorporate the objectives laid out in North West London
ICB’s medium-term financial strategy
• We will aim to allocate system funding to the health needs within the system and use payment mechanisms that facilitate the movement of care to the appropriate setting
• Work as a system to improve urgent and emergency care easing service pressures and reducing system cost.
• We will bring together specialist services to reduce duplication and cost whilst improving clinical pathways and clinical outcomes
• We will maximise the potential and effectiveness of London Ambulance Service (LAS), reducing the number of patients being transported to acute settings by increasing 111
services, more suitable pathways, the use of mental health cars that mean that mental health patients are initially seen by a mental health nurse, identifying and treating health
issues early and making the offering central to the emergency pathway
• We will aim to consolidate non-clinical functions looking to provide once for North West London wherever we can e.g. Procurement, Payroll, Business Intelligence & Occupational
Health
• We will work as a system to reduce our estate footprint and cost creating an affordable, sustainable fit for purpose rationalised estate in all sectors and North West London
boroughs
• Improve our digital capability supporting improved patient outcomes, digital patient access, data quality and business intelligence to drive continuous improvement with data
• Jointly invest in North West London assets e.g. hubs for simple medical procedures that are performed frequently, shared health records and increased expert opinion
• Create a more sustainable workforce that takes advantage of flexible working, new roles and links to planned activity and staff wellbeing
Primary Care
• Close the funding gap in all areas and target investment to communities with
highest need
• Continue to expand the single offer of enhanced services for general practice
• Reduce unwarranted clinical variation and advice and guidance to reduce referrals
to secondary care, prescribing and testing
• Ensure we get value for money for all we do, including continuing healthcare (CHC)
placements, prescribing and procurement
Acute Care
• Protect acute services by ensuring people only go to hospital when they need to and
improving support for them to leave hospital safely
• Work collaboratively to increase standardised approaches, reduce the cost base and
improve efficiency, using measures like Model Hospital and Reference Costs, bring our
expenditure in line with population need.
• Offer support to transfer services between organisations where there are inefficiencies
that cannot be improved – with appropriate public engagement
Mental Health Services
• Invest in mental health, funding the Mental Health Investment Standard and
establish a consistent set of services on offer to residents across North West
London
• Improve access and target investment to those communities with the highest need
• Have a consistent way of reporting to understand drivers of the cost base and
improve productivity
• Reduce the cost of, and reliance on, treating patients outside North West London
• Reduce service duplication by working as a system.
Community Care
• Establish a consistent offer for residents across North West London, funded by
improving efficiency
• Invest to ensure our out of hospital provision supports faster discharge of patients and
alternative patient pathways are available
• Have standard activity reporting to understand drivers of the cost base and improve
productivity.
• Improve efficiency, using measures like bench-marking against other providers and
average costs of secondary care in the NHS.
System levelProvider level
DRAFT
July draft for Health and Wellbeing Boards
PRIORITY 1: Reduce inequalities and improve health outcomes through population health management
Summary
The success of the Integrated Care Board will be judged by whether we have reduced inequalities in outcomes, access and experience for our residents and communities. We will do
this in three ways:
• By establishing a common set of services that all our residents can access, no matter where they live in North West London
• By working with our communities to tailor and improve access to those services, so that all residents have confidence in seeking access and in the experience they will receive
• By complementing these services in common with activities which address the holistic needs of our communities and where the needs of particular groups of residents cannot be
met by tailoring the services in common.
Population health management brings together health-related data to identify specific populations and/or individuals that can benefit from the tailoring of services, or from services that
are bespoke to their particular needs. This builds on the ‘Core20Plus5’ – improving the equity of experience, access and outcomes to those of our residents living in the most deprived
20% of neighbourhoods, in particular in the 5 areas NHS England has identified for both adults and children.
T o enable this, we will:
• Continue to expand the Whole System Integrated Care (WSIC) database, aligning this with other data sources to better understand need across our communities;
• Continue to foster closer working relationships with our communities to ensure that the quantitative data is supported by qualitative data and insight;
• Use this intelligence, and a comprehensive review of costs and activity, to support decisions which make the best use of resource and have the greatest impact on health and
wellbeing;
• Develop and implement approaches to co-producing solutions that meet specific hyperlocal needs and in turn build trust with our communities;
• Develop and roll out a Population Health Management and Health Equity Academy to develop core skills across the ICS, including how we meaningfully engage with our residents;
• Work closely with our partners to encourage a proactive, preventative approach that maximises our impact on the social, environmental and behavioural determinants of health;
• Build our capacity to effectively evaluate the work of the ICB and its partners;
• Use population health as an exemplar for how we introduce and scale innovations – starting with cardiovascular health – across North West London.
We will embed these approaches across all care settings, including borough-based partnerships, primary care and Integrated Neighbourhood T eams. We will also give all staff the
tools they need to demonstrate value and evidence impact, and systematically embed evaluation through all our work and build skills in our frontline staff to make every contact
count.
Through these changes we will reduce inequalities in access, experience and outcomes, increase levels of trust with marginalised communities, improve value for money and
opportunity to build on ‘what works’ across the system.
18
DRAFT
July draft for Health and Wellbeing Boards
PRIORITY 1: Reduce inequalities and improve health outcomes through population health
management
Case for change
• In in our least resourced neighbourhoods in North West London people are dying a over decade earlier than in other areas.
This is a long-standing issue and the inequalities gap in health and life expectancy has widened in recent years.
• When our communities don’t have the things they need, such as warm homes and healthy food, and are in low-paid or
unstable jobs, it can lead to chronic stress, poor physical and mental health and lives being cut short. For example, children
from households in the bottom fifth of income distribution are over four times more likely to experience severe mental
health problems than those in the highest fifth. There is a high level of overcrowded households in NW London, more than
double the national average, and this is strongly correlated with non-White British ethnicity
• Creating an environment which does not support healthy behaviours and lifestyles will also have a negative impact on
health – risk factors such as smoking and obesity are strongly causally linked to our population’s most common long term
conditions such as cardiovascular disease, chronic respiratory disease, cancers and diabetes. NWL’s hospital admission
rate is one of the highest in the country (even when taking into account the needs of our population), demonstrating that we
are not investing in upstream, proactive, preventative care.
• People from our different communities also have very different experiences of the health and care services that we provide,
including differential access to preventative care, meaning that we are not routinely identifying people early at risk of illness
and are diagnosing conditions later. Examples include gaps in the early diagnosis of prostate cancer amongst black
communities and in maternity outcomes for black and Asian mothers compared to white mothers.
• We are not tailoring services to be culturally competent to meet people’s needs, meaning that they are not provided in a
way that meets their cultural, ethical or religious needs. This is leading to very different and varying health outcomes in
different neighbourhoods.
• In a challenging financial environment, it is essential that activity across the system is aligned with need so spend can be
targeted on the most effective interventions to ensure equitable and proactive care for our population.
19
DRAFT
July draft for Health and Wellbeing Boards
Aim Target date Outcomes Dependencies Owner / governance
Improving
PHM
capability
Embed Population Health Management
(PHM) skills through PHM & Health
Equity Academy
March 2025
• Health and care services designed around the
needs of our communities
• Improved value for money through delivery of
services that are most appropriate for the local
population
• BI to enable data sharing and
investment in technology
• OD/CPOs to embed PHM skills in
BAU
• Health Equity Programme
team and board, PHM
steering group
• ICB effectiveness governance
PHM roll out across functions, including
primary care and INT s 2027/28
• PHM approach embedded in all services.
Services designed around population need and
addressing inequalities
• Primary care, community services
redesign
• Data and digital capabilities to enable
data-driven decision making in
different settings
• Health Equity Programme
team and board, Primary
Care Board
• Borough partners
Targeted
interventions
to reduce
healthcare
inequalities
Embed tools and frameworks to
address barriers to access and
differential outcomes, building a culture
of tackling inequity
2027/28
• Consistent system-wide approach to inequalities
• Improved trust in health and care services,
overcoming hesitancy and supporting delivery of
the common offer
• Clearer oversight of differences across North
West London and where action is needed,
through common core metrics
• Improved connection to local communities
• Reduced levels of digital exclusion
• Fewer access barriers related to communication
• Ownership of equity metrics/planning
by ICB teams, and commitment to
action plans
• Co-delivery of metrics with BI and
performance teams
• Digital team to improve access to
services
• Communications and engagement
• Health Equity Programme
team and Board, Data and
Digital programme boards,
wider Programme boards
Co-design interventions to reduce
inequalities in access, experience and
outcomes, focusing on areas of greatest
inequity.
2027/28
• Reduced variation with a focus on conditions with
worst outcomes/highest inequalities,
complementing common offer through additional
services tailored to need
• Integration of actions, incentives and tools to
drive equity for our population
• Prioritisation of Core20Plus5 clinical
areas in programme workplans
• Whole system collaboration
• On-going support from primary care to
increase reach, referrals, treatment
targets
• Health Equity Programme
team and wider Programme
boards, CRGs and North
West London ICB Board
Take action on
wider
determinants
of health
Build partnerships to address the wider
determinants of health 2027/28
• Reduced gap in healthy life expectancy
• Increased employment with focus on Core20Plus
• Reduced poor health related to housing
conditions
• Reduced levels of smoking and unhealthy weight
• Public health teams
• Local authorities and West London
Alliance
• NHS Trusts as Anchor institutions
• VCS organisations
• Programme team
• Local Authorities
PRIORITY 1: Reduce inequalities and improve health outcomes through population health management
What do we want to achieve?
20
DRAFT
July draft for Health and Wellbeing Boards
Aim Outcomes Dependencies Owner / governance
Enabling
functions
Workforce
• Increased local employment, increasing black and
ethnic minority staff in senior roles to reflect North
West London population
• PHM skills in workforce, including analytics and co-
production: services to better meet community
needs.
• More opportunities for Making Every Contact Count
• Business intelligence (BI) and data and
digital programmes
• Wider workforce programme
• Primary care workforce programme
• North West London People Board
with oversight by the Joint Lead
Chief People Officers
Data and digital
• Strategic reporting to support ICB teams, BBPs and
INT s, identifies inequalities and areas of need.
• Development of an easy to use front-end for
primary care, and other care settings, to case find
patients
• Interoperability with FDP to make use of
existing data feeds in Foundry and linking
with primary care and community data held
in WSIC
• North West London Data and
Analytics Steering Group,
reporting to Digital Transformation
Board and ICB Board
Communications
• Communication/engagement with communities are
culturally competent, build trust and reduce
inequalities
• Consistent approach to co-production with
communities, working with Borough teams
• Communities and engagement,
BBPs
PRIORITY 1: Reduce inequalities and improve health outcomes through population health management
What do we want to achieve?
21
DRAFT
July draft for Health and Wellbeing Boards
Aim Focus
year Year 1 Year 2 Year 3 +
Improving PHM
capability
Embed Population Health
Management (PHM) skills
through PHM & Health
Equity Academy
Year 1
• Delivery of PHM & Health Equity Academy –
upskilling ICS staff
• Map financial position to need (activity/costs
plus demographic, geographic etc. data)
• Expansion of PHM Academy with
focus on analytics across all staff
and working with ICS partners
• Start to develop a medium term
financial strategy aligned to need
• Embed PHM Academy into wider ICB training offer
and expand connection with system partners.
Monitoring and maintaining support in line with need.
• Development of ICS Intelligence Function –
supporting BI maturity against known
criteria/development framework
PHM roll out across
functions, including primary
care and INT s
Years 2-
3
• Trial PHM in Primary Care across
reactive, planned/preventative care services
• Start to roll-out clinical effectiveness
• Embed PHM in Primary Care
• Undertake impact assessment
• Fully embed clinical effectiveness
• PHM pilot in wider system and community; built on
learning.
• Identify functions to enable PHM
implementation/evaluation
• Embed PHM in all INT s to drive service design and
investment decisions.
Targeted
interventions
to reduce
healthcare
inequalities
Embed tools and
frameworks to address
barriers to access and
differential outcomes,
building a culture of
tackling inequity
Years 1-
2
• Focus on increasing trust, addressing
hesitancy, and digital inclusion
• Update inequalities metrics/dashboard
• Develop use of metrics and community insight
to drive action
• Embed equity in ICB processes
• Focus on addressing barriers
related to communication
• Consistent tracking of metrics;
spread equity index approach
• Embed co-production approach
• Deep dive and redesign of HIT
funding
• Deliver inequalities community impact report
• Redesign Health Inequalities Transformation funding
to have maximum impact, mainstreaming successful
interventions into BAU
• Embed closer link to communities and culture of
learning, sharing and co-production
Co-design interventions to
reduce inequalities in
access, experience and
outcomes, focusing on
areas of greatest inequity.
Years 1-
5
• Focus on hypertension, mental health,
maternity, and cancer diagnosis in black
communities
• Map inequalities in ICB priorities, using PHM
approach
• Implementation of High Intensity Use
programme in Urgent and Emergency Care
• Focus on diabetes and
gynaecological conditions
• T ackle inequalities in ICB
priorities, complementing
common offer
• T arget PHM approaches to deliver interventions to
reduce inequalities of access and outcomes across
other pathways
• Focus on specialist services and dementia
PRIORITY 1: Reduce inequalities and improve health outcomes through population health management
How will we achieve our outcomes?
22
DRAFT
July draft for Health and Wellbeing Boards
Aim Focus year Year 1 Year 2 Year 3 +
Take action on
wider
determinants
of health
Build partnerships to address the
wider determinants of health Year 1-4
• Focus on tobacco dependency
• T est system approach to, and
strengthen ICB delivery in prevention
through ICP priority areas (oral health,
vaccinations, and cancer screening)
• Focus on employment and housing
• Delivery of Anchor Charter and VCS
infrastructure support
• Focus on healthy weight
• Refresh Anchor Charter; and
monitor impact
• System volunteering strategy
• Grow VCS relationship and
support
• System-wide approach to proactive prevention
• Continued focus on healthy weight
• Roll out refreshed Anchor Charter and create
networks to share expertise and ideas
• Roll-out training on Making Every Contact Count
• Embed VCS ways of working and infrastructure
development
Enabling
functions
Workforce
• Embed PHM skills in BAU
• Deliver leadership training schemes for
local graduates
• Improve capability for data-driven decision making and engagement with communities
to reduce inequalities
• Create opportunities for Core20plus communities to access high-quality work, including
in health and care
Data and digital
• Link 111, 999, VCS data to WSIC
• Create population health dashboards for
whole sector
• Roll out Additional use cases for linked data
• Further development of technical PHM infrastructure
Communications • Improve ICB link to our communities: focus on engagement, culture of learning from and working with our communities, and targeted
and co-produced messaging.
PRIORITY 1: Reduce inequalities and improve health outcomes through population health management
How will we achieve our outcomes?
23
DRAFT
July draft for Health and Wellbeing Boards
PRIORITY 2: Improve children and young people’s mental health and community care
Summary
24
Our aim is to ensure for children, and young people to have the opportunity for the best start in life – leading safer, healthier, more fulfilling lives. Our strategy confirms we will do this
by:
• Implementing new ‘models of care’, for example: integrated neighbourhood teams of GPs, social workers, and community paediatric teams work identifying and reaching out to
families at risk of missing out on preventative care through family hubs and child health hubs;
• Establishing ‘system enablers’, for example: using innovative models of age-appropriate engagement and changing some of the contracts to incentivise preventative care; and
• Coordinating ‘programmes of work’ with the aim of reducing waiting times, improving access and focussing prevention activities where we know there are high inequalities of
outcomes.
Our focus in year one will be full implementation of the Thrive Framework to ensure comprehensive improvement across mental health services leading to a reduction in waiting times,
improved quality in CAMHS and a reduction in the high levels of mental health attendances for children. We will extend the successful model of family hubs and child health hubs
across all boroughs and focus on reducing inequalities in educational settings by ensuring children and young people with Special Educational Needs and Disabilities (SEND) or in
Local Authority Care (LAC), have the same access to specialist school nurses wherever they live.
Our focus in future years will
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