Brent is a London borough with a growing population. Brent is ranked amongst the top 15% most-deprived areas in the country, and is the 11th most deprived borough in London.

  • London North West Healthcare NHS Trust and Imperial College Healthcare NHS Trust are the main providers of acute and specialist care.
  • London North West Healthcare NHS Trust also provides community nursing and therapies.
  • Central North West London (CNWL) Foundation Trust is the main provider of mental health services.
  • Four networks have been set up (made up of Brent GP practices) to deliver extended primary care and out-of-hospital services for the Brent population.

Brent CCG 2015/16 annual report.

The chair of Brent CCG:

Dr Etheldreda Kong

Population demographics

  • 317,000*
  •  Brent is the most densely populated London Borough. The population density is 74.1 persons/hectare
  • The population is relatively young with 43% of residents under 30 years old, however more than 30,000 residents are aged 65 or over
  • Between 2011 and 2021 the population aged between 65 and 74 is expected to grow by 16%, 75-84 by 16% and 85+ by 72% whilst the total population will only grow by 7%
  • Brent is ethnically diverse with 65% from black, Asian and minority ethnic (BAME) backgrounds
  • More than 130 different languages are spoken in schools in Brent.

*based on 2013 ONS figures

Health challenges

  • Brent has a high number of people suffering from chronic disease and Long Term Conditions (LTCs). There was a 38% increase in the prevalence of diabetes between 2008/09 and 2012/13.
  • Hypertension, chronic heart disease and lung disease are all set to increase over the next five years.
  • The prevalence of severe and enduring mental illness in Brent is 1.14% of the population which is above both the London and England averages.
  • Brent children have worse than average levels of obesity – 11% of children aged 4-5, 24% of children aged 10-11 years
  • In Brent 46% of five-year-olds had one or more decayed, missing or filled teeth. This is worse than the England average of 28%.

Service improvements

Integrated care

  • Short Term Assessment Rehabilitation and Re-ablement service (STARRS): the fundamental driver is to provide care closer to home and in the patient’s home to avoid hospital stays and speed up discharge from hospital. The service is made up of a team of nurses, physiotherapists, consultant physician, social workers, speech and language therapists and healthcare support workers. In 2014/15, the service has prevented more than 2,700 hospital admissions.
  • Integrated Care Planning: giving patients with long-term conditions (LTC) a care plan that considered all their health and social care needs, keeping people healthier for longer and reducing the need for hospital care. Unmanaged long-term conditions are a major cause of emergency admissions to hospital, so better support through care plans is an essential part of reducing pressure on hospital services. Since care plans were introduced in 2012, we have supported more than 8,500 patients. Comparing LTC-related admissions between 2013/14 and 2014/15 shows a reduction in admissions of nearly 400.

Community and GP services

  • Ophthalmology and cardiology have been redesigned and commissioned as consultant-led community clinics. Also investing in cardiology diagnostic equipment (ECG) in GP surgeries.
  • Diabetes: in October 2014, an improved service for diabetics was launched offering multi-disciplinary diabetes care in GP and community health centres including extra self-management & education courses and podiatry capacity. The service will reduce the number of emergency admissions for diabetic patients through better support for patients to effectively self-manage their diabetes.
  • Patients on medication for arthritis and heart conditions now being monitored in primary care rather than hospital clinics providing support which is more co-ordinated with their wider health needs and helping to prevent conditions reaching crisis point and needed hospital admission.
  • More tests available from GPs for conditions including heart failure and inflammatory bowel disease.
  • Sickle Cell: after a successful pilot, in June 2015, on World Sickle Cell Day, we launched a new service to improve sickle cell care through a patient education and support programme with the aim of helping patients manage their condition and avoid crisis leading to emergency admissions.
  • Weekend and evening GP appointments: GP Access Hubs offer extended access to patients for all 66 practices in Brent. Appointments are available in the evening Mondays to Fridays, and daytime at weekends, as well as on bank holidays. There is a GP hub in place in each of the five localities.
  • Efficient appointments: 59 practices now offer telephone consultations and 55 practices offer online appointment bookings. Fifty-five also offer longer appointments to those that need them.
  • Elderly care: GP networks providing those in nursing homes and housebound patients with proactive care management to prevent deterioration and enable carers to better manage acute exacerbations. This has led to reduced demand for urgent care/hospital admission.
  • Improved buildings: Brent is investing in the estate needed to deliver more services in out-of-hospital settings. As well as developing GP hubs in each locality, three out-of-hospital hubs at Central Middlesex Hospital, Willesden and Wembley are being developed to deliver access to an extended range of integrated care for patients across Brent.

Mental health and wellbeing

  • Increased investment to improve access to psychology therapy to support patients with mild to moderate mental health illnesses.
  • Older adults: investment in crisis resolution home treatment team to support more elderly individuals in the community and prevent emergency admissions.
  • Established Primary Care Dementia Nurses for each locality within Brent, which has been in place since May 2014, to increase capacity for early diagnosis and provide early intervention as well as an effective interface between primary care and secondary care services for patients with dementia. The CCG and Brent Council also jointly commission a Dementia Café for patients and carers with dementia.
  • Primary Care Plus has been rolled out, offering greater support for mental health conditions from within general practice. GPs are able to offer more holistic support with their knowledge of patient's physical health record. In addition, the service provides care from a more relaxing environment, reducing the need for people to visit specialist mental health units for outpatient appointments.

Our future plans

Whilst we have made significant improvements, there is still more we want to do to improve care in Brent.

Integrated care

  • Improve management of long-term conditions by supplementing the current Integrated Care Programme model with Whole Systems Integrated Care early adopter sites in Harness and Kilburn, which will ‘go live’ during 2015. Early adopters will work with patients aged 65+ with one or more long term condition to proactive care management by the GP and supported by a team to deliver a range of interventions to promote better management of long-term conditions and access to crisis response support.
  • Enhance current STARRS service by reconfiguring and extending into a seven-day Integrated Rapid Response Service. The service demonstrates year-on-year improvement in admission avoidance. An increased focus on rapid response will address a known capacity gap. The changes will also bring integration with social care and help speed up hand-offs at an earlier point in the patient’s recovery.
  • Reconfigure existing discharge services to develop an Integrated Discharge Team to aid early and supported discharge of patients with complex needs who could be better cared for in the community.
  • Establish an Integrated Rehabilitation and Re-ablement Service with a single point of access to enhanced re-ablement support at home, preventing readmissions and improving clinical outcomes.

Mental health and wellbeing

  • Offer an urgent care mental health pathway integrated with adult social care, with recovery-focused support to address social factors (social isolation, unstable accommodation, and unstable employment) that increase the risk of a mental illness crisis.
  • Reconfigure existing services to provide more rapid crisis response, briefer and more intensive treatment, and transition support back to primary care (GP-led). Currently, GPs have few mental health resources, and more than 53% of adult community mental health patients have been in secondary care services for five years or more.
  • Brent CCG, in partnership with the North West London CCGs Collaboration, has recognised the need to improve out-of-hours Child and Adolescent Mental Health Services (CAMHS) provision and has agreed to invest an additional £140k as part of a £1.1m pilot which is aimed at improving the urgent care response to children and young people with a mental health crisis. The pilot will be undertaken during a comprehensive review of CAMHS in 2015/16 to inform the future service development required.

Community and GP services

  • Increasing access to services for the youngest in our community including further provision for CAMHS Tier 3 support (severe, complex and persistent needs), Children’s Integrated Nursing Team, and paediatric occupational therapy.
  • Develop Diabetes Insulin Initiation service within general practice to further strengthen GP and community based support for diabetic patients.
  • End of Life support with rollout of Co-ordinate My Care: a tool for patients with terminal illnesses that allows them to share decisions and wishes about their care with all health and care services supporting them. The tool supports patient choice, helps avoid hospital admissions and supports people to have a comfortable death.
  • Redesign new community based services, including ear nose & throat, paediatric phlebotomy, falls clinic and fracture liaison services.
  • Improving access to Primary Care and strengthening GP networks capability to manage more services within the community.
  • London Ambulance call out audit: the CCG is undertaking an audit of ambulance call outs by GPs to see if there is anything that can be done to further reduce pressure on London Ambulance Service and A&E.
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