Kensington & Chelsea

West London Clinical Commissioning Group (CCG) covers the Royal Borough of Kensington and Chelsea and also the Queen’s Park and Paddington area of Westminster.

  • Chelsea & Westminster NHS Foundation Trust and Imperial College Healthcare NHS Trust are the main providers of acute and specialist care.
  • Central London Community Healthcare (CLCH) provides community nursing and therapies.
  • Central and North West London NHS Foundation Trust is the acute mental health NHS provider with most treatment taking place in General Practice and also a diverse range of voluntary sector services.

West London CCG 2015/16 annual report.

The chair of West London CCG:

Dr Fiona Butler

Population demographics

  • 240,000*
  • The age profile of the area is common to other inner city areas in that it has a very large working age population and smaller proportions of children in particular (the second smallest in London).
  • Those aged 65 and above form a slightly larger proportion of the total population than London, but smaller than England.
  • Half the area’s population were born abroad.
  • Four in 10 (38%) of the population in Westminster and nearly a third (29%) of the population in Kensington and Chelsea is from black, Asian and minority ethnic (BAME) groups.
  • Over a quarter of the population state that English is not their main language

*based on 2013 ONS figures

Health challenges

  • The principle cause of premature (under 75 years of age) death in the area is cancer, followed by cardiovascular disease (which includes heart disease and stroke). A significant number of people also die from chronic obstructive pulmonary disease.
  • There are very high rates of people with severe mental illness (3,434) and enduring mental illness (12,972) in the area. • Priority areas for the CCG include people with long-term conditions, older people and homeless people.

Service improvements

Integrated care

  • Tri-borough Integrated Community Independence Service (CIS): a new health and social care service which supports people to stay independent at home for longer The service will be provided seven days a week, to provide rapid response services to support patients in their time of crisis to stay at home for longer where appropriate, services to bring people home sooner in conjunction with rehabilitation and re-ablement services to help people return to independent living as soon as possible. 
  • Primary Care Navigators (PCNs): there are 13 PCNs working in GP practices to help patients who are 55+ with physical and/or mental health needs. They achieve this by providing one-on-one support to patients in the community or local practices, informing them of NHS, Voluntary and Local Authority services that are available to them.
  • Integrated Care Planning: giving our most unwell patients a care plan that considers all aspects of their health and social care needs (with a particular focus on our most elderly), helps to ensure we keep people healthier for longer, reducing their need for hospital care and maintaining their independence. • Child Health GP Practice Hubs – provide an environment in which health and social care professionals can work together in multi-disciplinary teams to provide integrated care for children most in need.

Community and GP services

  • A range of community services have been redesigned with the aim of bringing care out of hospital and closer to home. They include:
    • Community Cardiology and Respiratory Service
    • Community Diabetes Service o Community Dermatology Service
    • Community Musculoskeletal Service
    • Community Ophthalmology Service (to be launched in Winter 2015)
  • To our most vulnerable patients designated nurses have been employed as ‘case managers’. The case manager’s role is to help coordinate the care for patients with complex needs spanning many services as well as providing key nursing services.
  • Prime Ministers Challenge Fund (PMCF): all 50 GP practices in West London are taking part to help make it easier for patients to see a GP at a time convenient to them.
  • GP Federation: as part of the Federation development process, all practices in West London Clinical Commissioning Group have agreed to work as a single federation, ensuring 100% population coverage across the CCG, and enabling further network development amongst GPs.
  • Extended access to GPs: patients can access weekend GP services at four practices offering a walk-in and booked appointments and referrals from 111 open to all West London patients. Two walk-in services are also available.
  • Enhanced access: we have invested in 28 practices which offer telephone consultations as an alternative to face-to-face appointments, five offering email consultations, 22 practices offer online appointment booking.
  • Improved buildings: West London is investing in the buildings needed to deliver more services outside hospitals and closer to patients’ homes. The St Charles Health and Wellbeing Centre is our north based out-of-hospital hub in which multiply services function from. A second out-of-hospital hub based in the south is currently under development.

Mental health and wellbeing

  • Urgent care/crisis services: the urgent care pathway has been redesigned to ensure that access to crisis and urgent mental health assessment and care is delivered at home, 24/7/365, and away from A&E departments and inpatient acute wards as far as possible by the end of 2015.
  • Our local dementia diagnosis rate remains high at 73% and we will continue to build on this success with a review of the dementia pathway, building on North West London-wide work and the Local Tri-Borough Joint Strategic Needs Assessment to ensure in particular the appropriate range of aftercare and support for patients and their carers.
  • Having achieved the national target of 15%, we will build on progress made during 2014/15 to increase the availability of talking therapies through Improving Access to Psychological Therapies, minimise waiting times, and increase the rate at which people move towards recovery to achieve 50% by the end of 2015. In particular we will target under-served groups, such as BME and over 65s through provision of a ‘mother tongue’ counselling service and better links between NHS and voluntary/community groups.
  • The vast majority of people with mental health problems access their GP for support, and when they do it is often for social rather than medical support, and for help to ‘stay well’ such as housing, activities or a physical health issue. It is vital therefore that we ensure that GPs have sufficient time to see patients with mental health problems, and also that they can draw on a robust multi-disciplinary team to work with patients and carers to get them the right care and support. Over the last year we have been working on such a ‘Community Living Well’ service, in partnership with service users, carers and the third sector, which we will start roll out of early in 2016. At the same time, we are rolling out an ‘Out of Hospital’ initiative with GPs to ensure minimum standards and appropriate remuneration for enhanced care.

Our future plans

Whilst we have made significant improvements, there is still more we want to do to improve care in Kensington and Chelsea and Queen’s Park Paddington.

Integrated care

  • West London CCG is implementing a new model of care for older people (aged over 65). The model aims to introduce better, more co-ordinated care. This means GPs, health services, social care, mental health and voluntary organisations working proactively together to help people stay well and improve outcomes. Care will centre on patients and empower them to direct their own care. In addition, care will have a higher degree of coordination with GPs who will sit at the centre of a multi-disciplinary team.
  • The services offered to patients will be determined by their specific health, mental health and social care needs. Those with the most complex needs will be offered the opportunity to receive holistic care planning and access to services at two newly designed hubs (with one hub in the south and one in the north of West London). GPs and other health and social care professionals will rotate through these hubs so that patients can access one-stop care in their local community. Patients who are mostly fit and well or who have fewer health and social care needs will be offered a care plan and supported to manage their own health and wellbeing, to enable them to remain well for as long as possible.
  • A key part of this model is the introduction of a self-care model of care, which is being piloted in 2015/16. The model focuses on self-care planning and goal setting, with patients being supported to access activities in the third sector to support their health and wellbeing. This may include physical activities, befriending services, condition-specific programmes and other services designed to reduce isolation, improve health and enable independence.
  • These new ways of working are being launched in phases across the West London CCG area, with some GP practices starting to deliver services from September 2015. The aim is for all GP practices to be participating by the summer/autumn of 2016.

Mental health and wellbeing

  • Ensure full delivery of Central and North West London’s single point of access and 24/7/365 crisis home response service by March 2016.
  • Implement our new integrated Community Living Well service by March 2017, with hubs at St Charles and Violet Melchett Health & Well-Being Centres.
  • Implement an integrated mental health employment pathway staff.
  • Develop a community-integrated perinatal mental health service in partnership with acute and mental health trusts, and the third sector by March 2017.
  • Continue to deliver against IAPT and Dementia targets, securing improved quality and impact for psychological therapies and targeting under-served groups.
  • Work with tri-borough local authority partners to review day services, dementia support pathways, and employment and housing initiatives.
  • Review Liaison Psychiatry Services at Chelsea and Westminster Hospital and St Mary’s Hospital to ensure they are delivering efficient, high quality services.

Community and GP services

  • Improving primary care and access: we will continue to ensure access to good quality primary care through extended evening and weekend opening.
  • Development of a south hub to deliver further services in the community.
  • Develop the federation of GP practices operating as a network across the CCG’s coverage area.
  • Increased investment in specialist neuro-rehabilitation and intermediate bed-based capacity ensuring the appropriate inpatient service is delivered as well as extending the provision of community rehabilitation services including enhanced support at home.
  • Create a single care home placement contracting team across health and social care in order to develop patient-focused outcomes-based specifications and ensure appropriate and timely provision reducing pressure on hospitals. 
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