Vin Diwakar: Sustainability and transformation plans in London

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  • Posted:Friday 15 September 2017

Speaking at a breakfast event on 12 September 2017, Vin Diwakar, London Regional Medical Director, NHS England, responds to The King's Fund's report on sustainability and transformation plans in London.


So good morning everyone.  Thank you for giving me the opportunity to discuss this report and the five sustainability and transformation partnership plans that we have here in London.  As you will have seen from my biography, I’m a paediatrician by background, now the regional medical director for London, for all of the last nine months.  I trained at St George’s Hospital which for those of you who don’t know is in Tooting, there’s a bit of a theme here, I’ve got great affection for that part of London as I do for London as a whole.

So as a paediatrician I’m still clinically active.  And when I do my ward rounds, the second question patients ask me after they’ve said ‘What’s wrong with my child doctor?’ is ‘When can I go home?’  There isn’t a single person that wants to be in hospital for a minute longer than they need to be.  And I’m a firm believer in two core principles, one is the best bed is your own bed.  Let’s keep people well, keep them out of hospital and make sure that hospitals are there only for you when you are sick.  And secondly that care is best centred when we organise it around individuals, around citizens, around patients, and not around our institutions.  And as such I think this report is welcome because of its support for the focus in London’s STP plans on prioritising prevention, on early intervention, on investing in primary care, and redesigning and reshaping the way we deliver services around citizens in our communities.

Now I feel optimistic about our ability to deliver some of these changes in London because of the strength of relationships that have built up between institutions and key leaders in London in recent years.  What are the reasons for this?  Well firstly there is a real clarity of purpose.  Tom has talked about the London Health Commission and how a few years ago it set an overarching goal for London to be the healthiest major global city, currently ranked seventh out of fourteen comparable cities for health, but ambitious plans set out as to how we plan to address that.  And the way in which the NHS, social care, communities and local government have come together in London, around better health for London, around the London devolution agreement, and the subsequent London Health Board, is one of the reasons why I professionally as a clinical leader came to work in London.  A topical example of this today is that Tom and Chris are about to shoot off to Stratford to be with the mayor in order to launch the Ask About Asthma campaign in which the mayor himself is supporting a campaign to raise awareness of three simple measures that you can take in order to improve the way in which we care for children with respiratory problems, with asthma in our community.  Something that can stop children from being admitted to hospital unnecessarily and reduce emergency admissions and something that can’t be done unless we work collectively across the NHS, social care and local government, partnership working where we can get the right people and the right expertise working well together in the right way.

Secondly I think the report acknowledges London has got an extremely impressive track record of transformational change.  Everyone talks about our past successes in stroke services in London, let’s remember that they were reconfigured amongst controversy and disapproval and doubts about whether they can be delivered, but they were delivered and ultimately 100 people a year survived from their stroke now where previously they would not have survived.  And on top of that those that suffer strokes are now less seriously disabled and spend less time in hospital than they would have done.  And changes in the way that we deliver major trauma care in the capital have been responsible for the way in which the NHS responded so magnificently to the recent terrorist atrocities.  

Thirdly however people might argue that the way that we delivered changes to stroke care and major trauma care in London were delivered in the past, but I think there’s evidence from what I’ve seen in my first nine months in my role in London that improvement and transformation continues to happen.  So despite the pressures on the NHS, when one looks overall, the emergency admissions in London last year rose by 0.4% which was much less than the rate of rise across the rest of the country.  Data from the London Ambulance Service shows that there used to be a significant number of care homes who frequently ring 999 when they’re worried about a frail elderly person in that setting.  The rate and conveyance of those patients from the care home to an emergency department was high, about 80% of 999 calls from care homes used to go up to emergency departments.  In January of this year London’s NHS opened a new telephone service, the dial 111 *5 *6 or *7 service where if you’re an ambulance crew, a care home worker or a community nurse, you could directly access a GP through a call back system for advice about the thing that you were worried about.  And over 60% of those calls, when they spoke to a GP, could be resolved by keeping our frail elderly fellow citizens safe in their environment in which they’re familiar with and not being taken to hospital.  That’s 3,400 fewer emergency admissions over the last six months, through providing better clinical support to 111, and it’s a demonstration of the sorts of thing we can do if we invest in the right way in community services.

And similarly London is the first English region in which you can get access to a GP 8:00am in the morning to 8:00pm at night seven days a week, that should help the entire health and care system across the piece.  Of course just getting the access there isn’t enough, we’ve got to focus on utilisation, and over this coming winter we will have a big focus on making sure that the public and that citizens know that service is there, and know how best to make use of it in order to make sure that we’re encouraging the public to use services in a way that best meets their needs.  

Fourthly I think STPs are in their infancy period, they have garnered success, but these are still iterative plans, that’s acknowledged in this report.  The analysis was done last March based on the plans that were set out last October, so over a year ago.  And since then an awful lot of work has been done on consulting on them and on refining them and on working them up in more detail.  And London’s STPs are developing well.  NHS England publishes a score card which some of you will have seen being published in July of this year, and London’s five STPs are grouped right in the middle two categories out of four.  So whilst we’ve got room for improvement, they’re clearly developing and going in the right direction.  London has got a great track record in engaging citizens in decisions about how our Health Service are organised, so in urgent and emergency care, the vision for London was developed by surveying over 1,000 Londoners and conducting face to face interviews with over 890 people attending emergency departments in every part of the city.  And more recently in the Great Weight Debate we engaged over 2900 Londoners in a debate about how we create solutions in communities to tackle obesity.  

My final two points are that it would be remiss of me as a clinician not to talk about clinical engagement.  London’s changes to stroke and trauma care were created by clinical leaders who came together with the public and with charities and with policy makers to create changes based on evidence.  That’s what we want to do here.  All of London’s STPs now have clinical boards that are up and running and are actively debating the key issues, the clinical evidence, in order to guide the changes going forward.  And CCG chairs and Trust medical directors are coming together for the first time collectively across the city with a clear sense of purpose about what sort of changes we think needs to be seen for better population health.

My final point is that STPs are really a vehicle for us to get all the relevant parties around the same table to develop solutions to problems.  We know that more work needs to be done to bring local authorities into that and to build on their expertise with the public.  We recognise that we cannot just bring people round the table and leave them to solve problems together, we have to provide them with proactive support.  And that’s why the NHS in London is investing for example in an improvement collaborative, which is being run jointly by the NHS and by the Association of Directors of Adult Social Care.  It’s a comprehensive range of activities in which we’re bringing together experts in hospital flow, in data analytics, in operational research, in bed modelling, together with clinicians and patients and specialists in quality improvement.  And they’re undertaking a whole series of both large scale and smaller scale events occurring in local areas looking at how we improve the quality of end of life care, discharge to assess, enhancing care in care homes, delayed discharge in mental health services, ambulatory care and frailty services.  And that for me is what sustainability and transformation partnerships are about, they’re about building effective relationships, creating ambitious plans and doing the work and providing the support in order to get them to happen.  Thank you very much.