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A way forward in integration

John Wardell, chief operating officer of Tower Hamlets clinical commissioning group, outlines how this pathfinder is gearing up to commission care for a borough with one of the most challenging demographics in the country.

People would probably argue that one of the things that characterises Tower Hamlets demographically is that we’re diverse.

Around 50% of the population is from an ethnic minority background. What stands out is that 34% of the population is from Bangladesh.

We’re the third most deprived borough in England, predicted to have a rapid population growth of 9% between 2009 and 2014. Some 35% of the population is under 25 years old, we have the highest rate of child poverty in England and the highest rate of overcrowding in London.

So we’re dealing with a lot of the social determinants of ill-health, along with significant challenges around long-term conditions.

We were set up in April 2010. Following consultation and a ballot of all GP partners and salaried and sessional GPs, it was agreed we should be led by a democratically elected board made up of GPs and other health professionals representing the eight Local Area Partnership areas in Tower Hamlets, plus other significant stakeholders.

We are co-terminous with our local authority.

The board includes one GP or practice partner from each Local Area Partnership area (a minimum of five GP principals and two salaried GPs), a nurse representative, a practice manager, an allied health professional, a local authority representative, a public health colleague, a patient forum representative and myself.

How we operate

Our response to our unique demographic make-up has been to bring groups of practices together by setting up integrated care networks in each of these Local Area Partnership areas.

Each network gets a management allowance and employs its own manager and clinical lead, and each practice is represented at a monthly board meeting.

The networks deliver a range of care packages for long-term conditions including diabetes, hypertension, COPD and cardiovascular disease as well as health checks.

Commissioning is now carried out at a network level, with 30% of payment linked to network outcome-focused delivery of the whole network.

We’ve already made a series of other improvements, including significant increases in immunisation coverage in the borough – which is now the highest in London.

We have also delivered a range of care-closer-to-home plans during 2010/11, including transferring 3,000 anticoagulation outpatient appointments into the community.

Our planned care programme includes redesigned care pathways for dermatology, urology, trauma, orthopaedics and ENT, commissioning new community pathways at 60% of full tariff and removing 16,600 episodes of activity out of the acute contract.

We’ve also established jointly chaired commissioning boards with primary and secondary care clinicians.

For example, one of the GP commissioners co-chairs an urgent care board with an A&E consultant, and this manages urgent primary care in casualty and primary care settings.

Borough-wide IT platform

Another achievement has been a unified EMIS system across the borough so that each practice has access to the same data. This has been a huge piece of work over the past two years or so. It has given us a solid  platform.

These information systems have helped us roll out care packages that include call and recall, documentation to support care planning, patient selection for multidisciplinary teams, data-sharing agreements and dashboard development, which enables real-time tracking of performance.

It also allows real-time tracking of those outcome measures codeable in GP IT systems to enable delivery against our vision of outcomes-led commissioning.

The network system has really helped in terms of patient engagement. For example, within the diabetes care package we’ve included a 45-minute meeting with a health professional about their care plan for each patient, and feedback suggests this is an empowering element.

We have access to multiple acute providers, but in effect, Barts and the London NHS Trust acts as our district general hospital. The majority of patients – 80 to 90% – still choose to go to Barts.

Integrated care

We were an integrated care pilot. Part of this entails further developing our partnership with the local authority and the acute provider. Integration, we feel, is the critical bit. We see that as fundamental to what we do.

With respect to the draft authorisation criteria announced last month, we’re going forward with the East London and City cluster, looking at taking on delegated responsibility for non-elective A&E and maternity services – around £50m-worth in shadow form from October.

We want to have full responsibility in shadow form from 2012/13 so we can demonstrate that we’re meeting the criteria for authorisation.

We’re one single CCG and are working hard to meet all the requirements for authorisation set out in the new guidance.  Over time we will take on responsibility for commissioning over £500m of services.

We’re not going to inherit a deficit. Last year we were within our control total and are still predicting to be on track this year. However, we will have to make significant savings going forward. We estimate the financial gap to be around £18m.


In terms of support we’re working with the new East London and City commissioning support service, along with four other local CCGs in shadow form. That’s providing us with holistic support for contracting, procurement, HR and other key functions for the delivery of strong commissioning.

We’re not looking at buying in any external support at present, although we will be engaging in the organisational development programme for NHS London’s pathfinding programme.

The future

In terms of what success will look like in the future, I think it’s all about integration. We want to develop a health system where all partners are equally involved. So the consultant working in secondary care has ownership of the 12,000 patients in their patch with diabetes just as much as the GP does.

We’re also trying to reduce the equality gap, ensuring we have the right pathways so that patients receive the right treatment from the right person at the right time.

I feel we’ve made a really good start. We’ve been helped by a very strong relationship between clinical leadership and general management. Our approach is widely supported in the borough and has been cited by both Londonwide LMCs and the BMA as a model of best practice.

John Wardell is chief operating officer of Tower Hamlets clinical commissioning group


Pathfinder: NHS Tower Hamlets CCG

Wave: Second

Practices: 36

Population: 245,000

PCT: NHS Tower Hamlets

Hospitals: Barts and the London NHS Trust

Demographics: Large areas of deprivation in the borough, including high levels of unemployment and overcrowding. Deaths from all causes per 100,000 population are 714 in Tower Hamlets compared with 381 in Kensington. Within the borough, life expectancy in Stepney is 8 years shorter for men and 6 years for women than in Millwall. The borough also has the highest rates of deaths due to smoking in London and deaths from cardiovascular disease, cancer and COPD are either the highest or second-highest in London.

Disease rates: The key health issues are cardiovascular disease, respiratory disease and diabetes, high numbers of low-birthweight babies, high incidence of dental decay in children, high rates of teenage pregnancy, high prevalence of HIV and sexually transmitted disease, high prevalence of depression and very high emergency hospital admissions for schizophrenia.

Source: NHS Tower Hamlets Annual Report 2009/10