Primary and secondary care

6.1 Key facts

• For males in Barnet, the life expectancy at birth for the most deprived 10% is 77.7 years, compared with 85.3 years for least deprived 10%; a gap of 7.6 years.
• The life expectancy for the least deprived 10% of females in Barnet (89.6 years) is 7.9 years higher than that for the most deprived (81.7 years).
• Between 2013/14 and 2017/18, the rate of emergency admissions for people of all ages in Barnet rose significantly. During this time, there were significant rises for children under 18, working aged people aged 16-64 and older people aged 65+ in the borough.
• In 2017/18 the rate of emergency admissions due to falls in people aged 65+ for Barnet (2,159 per 100,000) was significantly lower than London (2,319 / 100,000), but similar to England (2,170 / 100,000).
• During 2019, it is predicted that 15,527 older people in Barnet will suffer a fall, leading to 1,903 hospital admissions due to falling. This is the second highest number of hospital admissions for falls in all the London boroughs.
• The rate of elective admissions in Barnet fell significantly between 2013/14 and 2017/18 for working age people (aged 16-64) as well as for people of all ages. There was no significant change in the admission rates for children in Barnet aged 0-17 and older adults aged 65+.
• During 2017/18, the rate of A&E attendances for people of all ages (506.0 per 1,000) was significantly higher than both London (440.1 /1,000) and England (373.2 / 1,000). A similar pattern emerged for people aged under 18, 16-64 and 65+, when the Barnet rate was compared to London and national figures.
• Between 2013/14 and 2017/18, outpatient attendances in Barnet showed a significant increase for under 18s, people of working age (16-64 years) and all ages. Over this period, there was however a significant decrease in the rate of outpatient attendance for older people (aged 65+) in the borough.
• For 2019, there are an estimated 12,240 older people in Barnet with a limiting long-term illness whose day-to-day activities are limited a lot. This is the highest number of all 32 London boroughs.
• According to Better Care Fund (BCF) performance data for Quarter 2 of 2018/19 (June-September 2018), Barnet is not on track to meet its planned target for reducing non-elective admissions, but is on track to meet its targets for both residential admissions and delayed transfers of care (DToC).
• Between 2015/16 and 2017/18, the number of people in Barnet in nursing care rose by 8% from 387 to 419 and the number of adults living in residential homes fell from 1,160 to 1,001, a decrease of 14%.

6.2 Strategic needs

• There is a need for ongoing monitoring of life expectancy inequalities in Barnet, through the Health and Wellbeing Strategy, with a view to increasing life expectancies and healthy life expectancies, by decreasing gaps between wards and genders.
• By the year 2035, the number of people in Barnet aged 65+ having a fall is expected to rise to 23,530 (52% higher than 2019) and the number of hospital admissions due to falls to increase to 2,973 (56% higher).
• In recent years (between 2013/14 and 2017/18), there has been a significant rise in the rate of A&E attendances for Barnet, for people of all ages, under 18, aged 16-64 years, as well as older people aged 65+.
• Despite a decreasing trend in recent years, the rate of outpatient attendance for older people (aged 65+) in Barnet for 2017/18, was significantly higher than both London and England, so requires ongoing monitoring.
• Between 2020 and 2035, the estimated number of older people (aged 65+) in Barnet living with a limiting long-term illness whose daily activities are limited a lot, is projected to increase from 12,538 to 18,842, a rise of 50%.
• Given the substantial rises predicted in the number of older people in the borough with limiting long term illness, there is a clear need for integrated care systems within Barnet which promote independence in the elderly.
• Reducing the number of emergency hospital admissions and effectively managing both long term conditions and co-morbidities will be a challenge that requires the modification of primary and secondary care systems to allow more co-ordinated and integrated working across the North Central London CCGs.
• Within the North Central London CCG partnership, Barnet has been one of the first areas nationally to launch the new integrated urgent care model, which will require ongoing support.

6.3 Primary Care

According to NHS England; “Primary care services provide the first point of contact in the healthcare system, acting as the ‘front door’ of the NHS. Primary care includes general practice, community pharmacy, dental, and optometry (eye health) services.”[1] The World Health Organization sees primary health care as being centred around caring for people rather than simply treating specific diseases and conditions and that it can address most of an individual’s health needs over his/her life.[2]

[1] NHS England (2019). Primary care services. Available at: https://www.england.nhs.uk/participation/get-involved/how/primarycare/  

[2] World Health Organization (WHO, 2019). Primary Health Care (PHC). Available at:https://www.who.int/primary-health/en/

6.3.1 Barnet Clinical Commissioning Group (Barnet CCG)

Introduced in April 2013 as a replacement for Primary Care Trust (PCTs), Clinical Commissioning Groups (CCGs) are responsible for the planning and commissioning of health services within their local areas. Commissioning is an ongoing process, which involves obtaining the best possible health outcomes for a local population through the assessment of needs, development of policies and strategies and buying of services from local providers (e.g. hospitals and clinics).[3]

Barnet CCG is responsible for commissioning urgent and emergency services (including out-of-hours services), planned (elective) hospital services, maternity services, primary care services (delegated from NHS England), drugs prescribing by GPs, mental health and learning disability services and most community care for their local area.[4] This involves working closely with 55 GP practices, spread over three localities: North (26 practices); South (15 practices) and West (14 practices).[5]

Barnet CCG is led by an elected Governing Body, that has formal meetings every two months to discuss and decide upon changes to local health services. During 2017/18, this Governing Body was composed of:

• 9 Barnet GPs (one of whom acts as Chairperson)
• 4 lay (non-clinician) members
• 1 lead nurse
• 1 secondary care doctor
• 1 Accountable Officer
• 1 Chief Finance Officer and representatives from the Local Authority, Healthwatch and Public Health.[6]

As well as providing clinical leadership, managing providers and ensuring quality and effectiveness within the health care services of the borough, Barnet CCG is also tasked with delivering value for money against a background of limited resources and increasing demands and addressing health inequalities within the local population.[7]

[3] NHS Clinical Commissioners (NHSCC, 2019). About CCGs. Available at: https://www.nhscc.org/ccgs/

[4] Barnet Clinical Commissioning Group (Barnet CCG, 2018). Barnet CCG Annual Report and Accounts 2017-2018.

[5] London Borough of Barnet (2019).

[6] Barnet Clinical Commissioning Group (Barnet CCG, 2018). Barnet CCG Annual Report and Accounts 2017-2018.

[7] Barnet Clinical Commissioning Group (Barnet CCG, 2019). Our vision and values.

6.3.2 Life expectancy and health inequalities in Barnet

According to the World Health Organisation (WHO, 2019) “Health inequalities can be defined as differences in health status or in the distribution of health determinants between different population group. Some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions mainly outside the control of the individuals concerned.”[8]

Many factors are associated with health inequalities, including deprivation. In Barnet, the life expectancy at birth of males for the most deprived 10% is 77.7 years, which is 7.6 years lower than the life expectancy for the corresponding least deprived 10%, which is 85.3 years.[9] A similar pattern emerges for females in Barnet where the life expectancy for least deprived (89.6 years) is 7.9 years higher than that for the most deprived (81.7 years).[10]

However, the slope index of inequality (which looks at how much life expectancy changes with deprivation) found no significant change in life expectancy inequality in Barnet, since 2010-12, for either males[11] or females.[12] So the gap in life expectancy between the most and least deprived in the borough has remained relatively stable in recent years for both sexes.

The Joint Health and Wellbeing Board (JHWB) for Barnet is a strategic partnership of organisations across the borough and plays a key role in the local commissioning of health and social care as well as public health. One of the key responsibilities of the JHWB is addressing health inequalities across the borough. Linked to this, there is a commitment to the ongoing monitoring of these inequalities through the Health and Wellbeing Strategy 2015-2025, with a view to increasing life expectancies and healthy life expectancies by decreasing inequalities between wards and genders.[13]

[8] World Health Organization (WHO, 2019). Health Topics: Health Impact Assessment. Glossary of terms used. Health inequality and inequity.

[9] Public Health England (PHE, 2019). Local Authority Health Profiles. Life expectancy and causes of death. Life expectancy at birth (Male) Barnet, 2015 – 17. Available at: https://fingertips.phe.org.uk/profile/health-profiles/data#page/7/gid/1938132696/pat/6/par/E12000007/ati/102/are/E09000003/iid/90366/age/1/sex/1

[10] Public Health England (PHE, 2019). Local Authority Health Profiles. Life expectancy and causes of death. Life expectancy at birth (Female) Barnet, 2015-17. Available at: https://fingertips.phe.org.uk/profile/health-profiles/data#page/7/gid/1938132696/pat/6/par/E12000007/ati/102/are/E09000003/iid/90366/age/1/sex/2  

[11] Public Health England (PHE, 2019). Public Health Outcomes Framework. 0.2iii - Inequality in life expectancy at birth (Male). Available at: https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/data#page/4/gid/1000049/pat/6/par/E12000007/ati/102/are/E09000003/iid/92901/age/1/sex/1

[12] Public Health England (PHE, 2019). Public Health Outcomes Framework. 0.2iii - Inequality in life expectancy at birth (Female). Available at: https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/data#page/4/gid/1000049/pat/6/par/E12000007/ati/102/are/E09000003/iid/92901/age/1/sex/2

[13] Joint Health and Wellbeing Board (2015). Joint-Health-and-Wellbeing-Strategy-2015-2020 (p. 28). Available at: https://www.barnet.gov.uk/citizen-home/public-health/Key-strategic-documents-and-plans/Joint-Health-and-Wellbeing-Strategy-2015-2020.html

6.4 Secondary Care

When a health problem cannot be effectively treated in a primary care setting because it requires more specialised knowledge, equipment and /or skills, a referral to secondary care services is necessary.[14] Secondary care refers to services which are often not the first point of contact for the patient and are usually based in hospital and clinic settings, although some secondary care services are community based. Secondary care includes for example planned (elective) operations, specialist clinics (such as cardiology) and rehabilitation services (e.g. physiotherapy).[15]

[14] Health Talk (2019). Seeing the GP: Advice and tips for young people. What is secondary care? Available at:http://www.healthtalk.org/young-peoples-experiences/seeing-gp-advice-and-tips-young-people/what-secondary-care 

[15] Multiple Sclerosis Trust (2019). Care in the NHS. Secondary care. Available at:https://www.mstrust.org.uk/a-z/care-in-the-nhs#secondary-care

6.4.1 Emergency Admissions

An emergency admission is “unpredictable and at short notice because of clinical need.”[16] Most emergency admissions are unavoidable and clinically appropriate, however some could be avoided through prevention and the provision of appropriate care and support, as well as alternative forms of urgent care. In 2016-17, there were 5.8 million emergency admissions in England, up 2.1% from the previous year and they continue to increase each year. For 2016/17, NHS England considered almost a quarter (24%) of these emergency admissions to be avoidable.[17]

During 2017/18, there were on average 16,480 emergency admissions to hospitals in England each day, which was a 3.7% increase over the previous year and a 15.7% increase over the previous 5 years. Most of this growth is due to “zero-day admissions” in which people are discharged without an overnight stay, which suggests that the increase in emergency admissions is not just caused by a rise in demand.[18] The growth of emergency admissions in England between 2013-14 and 2016-17 was mainly accounted for by people who did not stay overnight (79%), with over half (53%) of this increase from older people (aged 65+).[19]

Between 2013/14 and 2017/18, the rate of emergency admissions for people of all ages in Barnet rose significantly. Over the same period, there were also significant rises for children under 18, working aged people aged 16-64 and older people aged 65+ in Barnet (see Figure 6.1). During this period, both London and England also showed significant increases in the rate of emergency admissions for people in all these age groups.

In 2017/18, the rate of emergency admissions for people of all ages in Barnet (79.1 / 1000) was significantly lower than both London (87.4) and England (107.1). For children aged under 18, the emergency admission rate in the borough (48.9 / 1000) for 2017/18, was also significantly lower than both London (58.8) and England (75.2). Similarly, for people aged 16-64, the rate of emergency admission in Barnet (50.0 / 1000) was significantly lower than both London (60.6) and England (72.5). However, whilst older people in Barnet had a lower emergency admission rate (255.6 / 1000) compared to London (290.4), the borough rate for 2017/18 was similar to the emergency admissions rate for England (258.3 / 1000).[20]

Figure 6.1: Rate of emergency admissions for Barnet per 1,000 population by age, persons, 2013/14 – 2017/18.

Source: NHS Digital (HES data) and GLA projection data (Central trend)

Against this background, in 2017/18 the rate of emergency admissions due to falls in people aged 65+ for Barnet (2,159 per 100,000) was significantly lower than London (2,319 / 100,000) but similar to England (2,170 / 100,000). As can be seen from Figure 6.2, Barnet had the 11th lowest rate of emergency admissions for falls in older people, when compared to other London boroughs. Since 2013/14, this admissions rate has been significantly lower than London and either similar or lower than the England rate.[21]

Figure 6.2: Directly standardised rate of emergency admissions (per 100,000) due to falls in older people (aged 65+) for Barnet, London, England and the London boroughs, 2017/18

Source: PHE, 2019: Public Health Profiles. Based on data from NHS Digital and ONS.

Key: Red: Significantly worse than England. Yellow: Similar to England. Green: Significantly better than England.

[16] NHS Digital (2018). Data dictionary. Admission Method: Emergency Admission. Available at:https://www.datadictionary.nhs.uk/data_dictionary/attributes/a/add/admission_method_de.asp

[17] National Audit Office (NAO, 2018). Report by the Comptroller and Auditor General (HC 833). Reducing emergency admissions. 2 March 2018. Available at: https://www.nao.org.uk/wp-content/uploads/2018/02/Reducing-emergency-admissions-Summary.pdf

[18] Baker, C. (2018). House of Commons Library briefing paper (number 7281, 1 October 2018). NHS Key Statistics: England, October 2018. Available at: http://researchbriefings.files.parliament.uk/documents/CBP-7281/CBP-7281.pdf

[19] National Audit Office (NAO, 2018). Report by the Comptroller and Auditor General (HC 833). Reducing emergency admissions. 2 March 2018. Available at: https://www.nao.org.uk/wp-content/uploads/2018/02/Reducing-emergency-admissions-Summary.pdf

[20] NHS Digital (2019). Hospital Episode Statistics and Greater London Authority (GLA, 2019). GLA Population and Household Projections. Central Trend (detailed and national).

[21] Public Health England (PHE, 2019). Public Health Profiles. 2.24i - Emergency hospital admissions due to falls in people aged 65 and over, 2017/18. Available at:https://fingertips.phe.org.uk/search/falls#page/3/gid/1/pat/6/par/E12000007/ati/102/are/E09000003/iid/22401/age/27/sex/4

6.4.1.1 Falls

Falls are a common and serious problem for older people aged 65+, who are the age group most at risk of falling. Around 30% of people aged 65+ fall at least once a year, rising to 50% for those aged 80+.[22] The human and financial costs associated with falling are enormous, with the total cost of frailty fractures estimated at £4.4 billion (of which £1.1 billion is social care and around £2 billion due to hip fractures). As well as causing pain, injury, distress, loss of confidence and independence, hip fractures are also associated with a 18-33% increase in one-year mortality and a negative impact on activities of daily living. The effect on the health and quality of life of those elderly people who fall, their families and carers can therefore be substantial.[23]

Barnet currently has a large population of older people (aged 65+) which is projected to increase substantially in the coming years. This rise in the older population has potentially serious implications for secondary care admissions, as greater number of frail elderly people suffer traumatic falls that require unplanned hospital admissions.

During 2019, it is predicted that 15,527 older people in Barnet will suffer a fall, leading to 1,903 hospital admissions due to falling. This is the second highest number of hospital admissions for falls in all the London boroughs (see Figure 6.3).

Figure 6.3: Estimated number of hospital admissions for falls in people aged 65+, London boroughs, 2019

Source: POPPI

By the year 2035, the number of people in Barnet aged 65+ having a fall is expected to rise to 23,530 (52% higher than 2019) and the number of hospital admissions due to falls to increase to 2,973 (56% higher). Figure 6.4 depicts the steady rise in the number of hospital admissions due to falls for older people in Barnet between the years 2020 and 2035.[24]

Figure 6.4 Projected number of hospital admissions due to falls in older people (aged 65+) for Barnet, 2020-2035

Source: POPPI

There are over 400 risk factors associated with falls and the likelihood of falling increases with the number of risk factors. A previous history of falling is the single most important risk factor and is a strong predictor of future falls and for this reason NICE recommends that older people at risk of falling should be asked about falls during routine reviews by health and social care practitioners. Where appropriate, a multifactorial risk assessment can then be carried out by practitioners with skills and experience in falls prevention, to identify and address risk factors associated with falling through an individualised multifactorial intervention.[25]

Around 20% of hip fracture patients enter long term care within one year of the fracture[26] and given the high health and social costs associated with falls in the elderly, in terms of care, support and rehabilitation, there are clear benefits to Barnet reducing the number of admissions due to falls within its older population.

[22] National Institute for Health and Care Excellence (NICE, 2013). Guidance: Falls in older people: assessing risk and prevention. Available at: https://www.nice.org.uk/guidance/cg161/chapter/Introduction  

[23] Public Health England (PHE, 2018). Guidance: Falls: applying All Our Health. Available at:https://www.gov.uk/government/publications/falls-applying-all-our-health/falls-applying-all-our-health

[24] Projecting Older People Population Information System (POPPI, 2018). Falls & Falls - hospital admissions. Available at: http://www.poppi.org.uk/index.php?pageNo=339&areaID=8335&loc=8335 

[25] National Institute for Health and Care Excellence (NICE, 2017). Falls in older people. Quality standard [QS86]. Available at: https://www.nice.org.uk/guidance/qs86/chapter/Quality-statement-2-Multifactorial-risk-assessment-for-older-people-at-risk-of-falling

[26] Public Health England (PHE, 2018). Guidance: Falls: applying All Our Health. Available at:https://www.gov.uk/government/publications/falls-applying-all-our-health/falls-applying-all-our-health

6.4.2 Elective Admissions

According to NHS Digital; “An Elective Admission is one that has been arranged in advance. It is not an emergency admission, a maternity admission or a transfer from a Hospital Bed in another Health Care Provider. The period that the patient has to wait for admission depends on the demand on hospital resources and the facilities available to meet this demand.”[27]

Each month there are around 700,000 G&A (General & Acute Specialties) elective admissions in England, of which 80% are day cases[28] (where a patient is admitted to hospital for a procedure and returns home on the same day as planned).[29]

Between 2013/14 and 2017/18, the rate of elective admissions in Barnet fell significantly for working age people (aged 16-64) and people of all ages. There was no significant change in the rates for children in Barnet aged 0-17 and older adults aged 65+ (see Figure 6.5). In contrast, the rate of elective admissions in both London and England showed a significant increase for people aged 16-64, 65+ and people of all ages. However, over the same period, the elective admission rate for children aged 0-17 showed no change in London, but a significant decline in England.

Figure 6.5: Rate of elective admissions for Barnet per 1,000 population by age, persons, 2013/14 – 2017/18.

Source: NHS Digital (HES data) and GLA projection data (Central trend)

In 2017/18, the rate of elective admissions for people in Barnet was significantly lower than England for all age groups under consideration (0-17, 16-64, 65+ and all ages). For people of all ages, the elective admissions rate in 2017/18 for Barnet (123.7 / 1000) was similar to London (125.0 / 1000). This was also the case for older adults aged 65+, where Barnet and London had the same rate of 340.0 / 1000 for that year. However, for children aged 0-17 and working age adults (aged 16-64) the rate of elective admissions for 2017 /18 was significantly lower than London.[30]

[27] NHS Digital (2018). Data dictionary. NHS Business Definitions. Elective Admission. Available at:https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/e/elective_admission_de.asp?shownav=1

[28]  Baker, C. (2018). House of Commons Library briefing paper (number 7281, 1 October 2018). NHS Key Statistics: England, October 2018. Available at: http://researchbriefings.files.parliament.uk/documents/CBP-7281/CBP-7281.pdf

[29] NHS Digital (2018). Data dictionary. NHS Business Definitions. Patient Classification. 2 Day case admission. Available at:https://www.datadictionary.nhs.uk/data_dictionary/attributes/p/pati/patient_classification_de.asp

[30] NHS Digital (2019). Hospital Episode Statistics and Greater London Authority (GLA, 2019). GLA Population and Household Projections. Central Trend (detailed and national).

6.4.3 A&E attendances

“An Accident and Emergency Attendance is an individual visit by one patient to an Accident and Emergency Department to receive treatment from the accident and emergency service.”[31] According to NHS Digital; “Accident and Emergency Departments may be either major units, providing a 24-hour service seven days a week to which the great majority of emergency ambulance cases are taken, or small units commonly called casualty departments, in which services are often only available for limited hours and which may not deal with emergency ambulance cases. An accident and emergency service offers care to patients who arrive with urgent problems and who have not usually been seen previously by a general practitioner.”[32]

Each day, during the first eight months of 2018, an average of 67,000 people attended A&E departments in England, which was a 3.9% increase on the same period in 2017. For major A&E departments (with a 24-hour service) attendance has increased by 7.3% in the last five years, which represents almost 3,000 extra people attending each day.[33]

Between 2013/14 and 2017/18 there was a significant rise in the rate of A&E attendances for Barnet, London and England, for all the age groups under consideration (All ages; under 18, 16 to 64 years as well as older people aged 65+). The increase in the rate of A&E attendance for Barnet, during this period, is shown in Figure 6.6.

Figure 6.6: Rate of A&E attendances for Barnet per 1,000 population by age, persons, 2013/14 – 2017/18.

Source: NHS Digital (HES data) and GLA projection data (Central trend)

During 2017/18, the rate of A&E attendances for people of all ages (506.0 per 1,000) was significantly higher than both London (440.1 /1,000) and England (373.2 / 1,000). A similar pattern emerged for all the other age groups, when the Barnet rate was compared to regional and national figures. For children aged under 18, the A&E attendance rate in 2017/18 was 501.0 per 1,000, significantly higher than both London (458.5 / 1,000) and England (410.2 / 1,000). Similarly, for working age people aged 16-64 years, the rate of A&E attendance was 460.3 per 1,000 population which was significantly higher than both London (401.2 / 1,000) and England (339.2 / 1,000). For older people aged 65+, the disparity was even more pronounced, with the A&E attendance rate for older adults in the borough (704.7 per 1,000) significantly higher than London (613.4 / 1,000) and England (444.1 / 1,000).[34]

[31] NHS Digital (2018). Data dictionary. NHS Business Definitions. Accident and Emergency Attendance. Available at:https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/a/accident_and_emergency_attendance_de.asp?shownav=1

[32] NHS Digital (2018). Data dictionary. NHS Business Definitions. Accident and Emergency Department. Available at:https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/a/accident_and_emergency_department_de.asp?shownav=1

[33] Baker, C. (2018). House of Commons Library briefing paper (number 7281, 1 October 2018). NHS Key Statistics: England, October 2018. Available at: http://researchbriefings.files.parliament.uk/documents/CBP-7281/CBP-7281.pdf

[34] NHS Digital (2019). Hospital Episode Statistics and Greater London Authority (GLA, 2019). GLA Population and Household Projections. Central Trend (detailed and national).

6.4.4 Outpatient Attendances

Each month, there are about 1.5 million first outpatient attendances in England as well as 1.1 million GP referrals. Between 2009 and 2016, first outpatient attendances rose by 12% faster than population growth and GP referrals by 15% faster. However, in 2017, both first outpatient attendances and GP referrals fell.[35]

An outpatient attendance is one that takes place in an outpatient clinic which is; “an administrative arrangement enabling patients to see or be in contact with a care professional at a Consultant Clinic, Nurse Clinic, Midwife Clinic, Sexual and Reproductive Health Clinic, or at any other clinic.”[36]

Between 2013/14 and 2017/18, outpatient attendances in Barnet showed a significant increase for under 18s, people of working age (16-64 years) and all ages. Over this period, there was however a significant decrease in the rate of outpatient attendance for older people (aged 65+) in the borough, falling from 4424.4 per 1,000 to 4302.7 per 1,000 (see Figure 6.7). In London and England, the rate of outpatient attendance increased over this period for all age groups under consideration, including older people.

Figure 6.7: Rate of outpatient attendances for Barnet per 1,000 population by age, persons, 2013/14 – 2017/18.

Source: NHS Digital (HES data) and GLA projection data (Central trend)

During 2017/18, the rate of outpatient attendance in Barnet for people of all ages was 1754.2 per 1,000, which was similar to London (1750.0 / 1,000), but significantly higher than England overall (1658.7 / 1,000). In contrast, the rate for under 18s in the borough (782.0 per 1,000) was significantly lower than both London (790.7 / 1,000) and England (823.3 / 1,000). For those of working age (16-64 years old), the rate of outpatient attendance in 2017/18 was 1522.1 per 1,000 population, which was significantly lower than London (1641.9 / 1,000), but significantly higher than England (1441.0 / 1,000). For older adults (aged 65+), the rate of outpatient attendance in Barnet was 4302.7 per 1,000, which was significantly higher than both London (4105.6 / 1,000) and England (3312.7 / 1,000).[37]

[35] Baker, C. (2018). House of Commons Library briefing paper (number 7281, 1 October 2018). NHS Key Statistics: England, October 2018. Available at: http://researchbriefings.files.parliament.uk/documents/CBP-7281/CBP-7281.pdf

[36] NHS Digital (2018). Data dictionary. NHS Business Definitions. Out-Patient Clinic. Available at:https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/out-patient_clinic_de.asp?shownav=1

[37]NHS Digital (2019). Hospital Episode Statistics and Greater London Authority (GLA, 2019). GLA Population and Household Projections. Central Trend (detailed and national).

6.5 Integrated care

According to NHS England; “For health, care and support to be ‘integrated’, it must be person-centred, coordinated, and tailored to the needs and preferences of the individual, their carer and family. It means moving away from episodic care to a more holistic approach to health, care and support needs, that puts the needs and experience of people at the centre of how services are organised and delivered.”[38] A widely used definition of integrated care is provided by “National Voices,” a coalition of charities which promote person centred care. According to this definition, integrated care is person centred, based on better planning, involves more personal involvement of the service user and promotes free access to good quality information.[39]

The Health and Social Care Act 2012 placed a responsibility on local authorities to establish Health Wellbeing Boards (HWBs) for their areas. These boards have the duty to promote integration with a view to improving the quality of health services and reducing inequalities amongst those accessing services. HWBs must also encourage Clinical Commissioning Groups (CCGs) to enter relationships with local authorities to ensure that health services are provided in an integrated way.[40]

In May 2013, NHS England as one of the key partners of the “National Collaboration for Integrated Care and Support” signed up to the first systems wide shared commitment in this country to help local areas to deliver integrated care and support. Within this commitment, there was a clear recognition that with people now living longer and children reaching adulthood with several complex long-term conditions, there was a need to move away from a fragmented health care system towards a person-centred, integrated one.[41]

A report for the Department of Health summarised the importance of integrated care in the following way; “Integrated care is essential to meet the needs of the ageing population, transform the way that care is provided for people with long-term conditions and enable people with complex needs to live healthy, fulfilling, independent lives.”[42] Against this background, Barnet Integrated Locality Team (BILT) co-ordinates the care of older borough residents with complex health needs and supports their carers.[43]

[38] NHS England (2019). Integrated care and support. Available at:https://www.england.nhs.uk/ourwork/part-rel/transformation-fund/

[39] National Voices (2013). Think Local Act Personal: A Narrative for Person-Centred Coordinated Care. Available at: https://www.nationalvoices.org.uk/publications/our-publications/narrative-person-centred-coordinated-care

[40] The Stationery Office (TSO, 2012). Health and Social Care Act 2012. Available at:http://www.legislation.gov.uk/ukpga/2012/7/pdfs/ukpga_20120007_en.pdf

[41] National Collaboration for Integrated Care and Support (2013). Integrated Care and Support: Our Shared Commitment, May 2013. Available at:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/198748/DEFINITIVE_FINAL_VERSION_Integrated_Care_and_Support_-_Our_Shared_Commitment_2013-05-13.pdf

[42] The King’s Fund and the Nuffield Trust (2012). A report to the Department of Health and the NHS Future Forum. Integrated care for patients and populations: Improving outcomes by working together. Available at:https://www.kingsfund.org.uk/sites/default/files/integrated-care-patients-populations-paper-nuffield-trust-kings-fund-january-2012.pdf

[43] London Borough of Barnet (2019). Barnet Integrated Locality Team (BILT).

6.5.1 Long Term Conditions (LTCs)

According to the Department of Health; “A long term condition (LTC) is a condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies.” Also known as “chronic conditions,” they include diabetes, hypertension, asthma, cancer and dementia and affect an estimated 15 million people in England. A higher prevalence of these conditions is found amongst older and more deprived populations, where there are also higher levels of co-morbidity (where a person has more than one LTC). In 2018, there were an estimated 2.9 million people in England with three or more LTCs (compared with 1.9 million in 2008). The way the NHS has been configured to deal with LTCs is not sustainable in the face of increasing co-morbidity and the growing needs of an ageing population.[44]

As the older population increases and with it the prevalence of LTCs and co-morbidity, the previous NHS system of disjointed, fragmented and episodic care is unsustainable. However, long term conditions are a “central task for the NHS” and the importance of integrated care in dealing with the increasing demand created by them is appreciated.

In October 2014, NHS England published the “Five Year Forward View” (FYFV) aimed at allowing people with LTCs to “live well, age well and die well.” This plan called for better integration between primary and secondary care services, including mental health, as well as more joined up working between care homes and home care services.[45] Early results from the FYFV, from so-called “vanguard areas,” have reported reduced growth in emergency admissions and less time spent in hospital compared with other parts of the country, especially for older people aged 75+.[46]

The older population of Barnet is predicted to increase substantially in the years preceding 2030 which has serious implications for both cost and service provision related to LTCs, including dementia. For 2019, there are an estimated 12,240 older people in Barnet with a limiting long-term illness whose day-to-day activities are limited a lot. This is the highest number of all 32 London boroughs (see Figure 6.8).[47]

Figure 6.8: Estimated number of older people (aged 65+) with a limiting long-term illness whose day-to-day activities are limited a lot, London boroughs, 2019

Source: POPPI

Between 2020 and 2035, the estimated number of older people (aged 65+) in Barnet living with a limiting long-term illness whose daily activities are limited a lot, is projected to increase from 12,538 to 18,842, a rise of 50%. Similarly, over the same period, the estimated number of older people in the borough with a limiting long-term illness whose activities are limited a little is predicted to rise from 13,982 to 20,476, an increase of 46% (see Figure 6.9).[48]

Figure 6.9: Estimated number of older people (aged 65+) in Barnet with a limiting long-term illness whose day-to-day activities are limited a little / lot, 2020-2035

Source: POPPI

Given the substantial rises predicted in the number of older people in the borough with limiting long term illness, the need for integrated care systems within Barnet which promote independence in the elderly is clearly underlined. Reducing the number of emergency hospital admissions and effectively managing both long term conditions and co-morbidities will be a challenge that requires the modification of primary and secondary care systems to allow more co-ordinated and integrated working across the borough. The relatively large older population in Barnet is projected to increase by around a third by 2030, so greater integration of primary and secondary care systems within the borough to facilitate the care of long term conditions and co-morbidities would be beneficial.

[44] Department of Health (DH, 2012). Long Term Conditions Compendium of Information, Third Edition. Available at: http://www.workingtowardswellbeing.com/wp-content/uploads/2012/09/2012-LTC-Compendium-of-Information-Third-Edition-FINAL-2.pdf

[45] NHS England (2019). Our work on long term conditions. Available at:https://www.england.nhs.uk/ourwork/clinical-policy/ltc/our-work-on-long-term-conditions/

[46] NHS England (2017). Next Steps on the NHS Five Year Forward View. Available at:https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf

[47] Projecting Older People Population Information System (POPPI, 2018). Limiting long term illness: People aged 65 and over with a limiting long-term illness, by age, projected to 2021. Available at:http://www.poppi.org.uk/index.php?pageNo=331&areaID=8648&loc=8648

[48] Projecting Older People Population Information System (POPPI, 2018). Limiting long term illness: People aged 65 and over with a limiting long-term illness, by age, projected to 2035. Available at:http://www.poppi.org.uk/index.php?pageNo=331&PHPSESSID=hvvp649i84l61426h0hjf7n5p3&sc=1&loc=8335&np=1

6.5.2 Better Care Fund

During the June 2013 spending round, the Government announced the £5.3 billion Better Care Fund (BCF) programme to transform the integration of health and social care, through a collaboration between the Local Government Association, NHS England, Department of Health and Social Care (DHSC) and the Ministry of Housing, Communities and Local Government (MHCLG). Based on the vison outlined in the 5-Year Forward View (FYFV), these four partners have been tasked with assisting local areas across England with the implementation of integrated health and social care services. The BCF encourages closer working and integration at a local level by requiring local authorities and CCGs to agree integrated spending plans based on pooled budget arrangements.[49]

At a local level, the Health and Wellbeing Board (HWB) oversees the strategic direction of the BCF in the delivery of better integrated care for people in Barnet, including those with long term conditions, by meeting its statutory duty to encourage integrated working between commissioners within the borough.[50] In achieving this, the aim is to shift resources and activity from long term hospital and residential care towards care in the community based on a person-centred, coordinated approach.[51]

According to quarterly BCF performance data for Quarter 2 (2018/19) covering the period June - September 2018, Barnet is not on track to meet its planned target for reducing non-elective admissions, but is on track to meet its targets for both residential admissions and delayed transfers of care (DToC).[52]

[49] NHS England (2019). Better Care Fund. Available at: https://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/

[50] NHS England (2018). The Integration and Better Care Fund Operating Guidance For 2017-19. Available at:https://www.england.nhs.uk/wp-content/uploads/2018/07/better-care-fund-operating-guidance-v1.pdf

[51] Local Government Association (2019). Better Care Fund. Available at: https://www.local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/integration-and-better-care-fund/better-care-fund

[52] NHS England (2018). Better Care Fund: quarterly performance report 2018/19. Quarter 2 data collection and performance report 2018/19 (July – September 2018). Available at:https://www.england.nhs.uk/publication/better-care-fund-quarterly-performance-report-2018-19/  

6.5.2.1 Delayed Transfer of Care (DTOC)

According to NHS England; “A delayed transfer of care (DTOC) from NHS-funded acute or non-acute care occurs when an adult (18+ years) patient is ready to go home and is still occupying a bed.” Three conditions must be met before a patient is ready to go home; (1) a clinical decision confirms that the patient is ready to transfer home; (2) a decision by a multidisciplinary team (MDT) has been made confirming that the patient is ready to transfer home and (3) it is considered to be safe for the patient to be discharged / transferred home.[53]

As soon as a patient meets these three criteria they are classified as a “delayed transfer.” All hospitals in England are required to collect data on DTOCs and send it to NHS England. As they have serious cost implications, cause distress and unnecessarily long hospital stays for patients as well as contributing to waiting times by reducing the number of beds available, DTOCs are a serious concern within the healthcare system.[54] This importance is reflected by the inclusion of DTOCs in the Better Care Fund (BCF) performance metrics.[55]

Figure 6.10 shows Delayed Transfer of Care (DTOC) for Barnet between December 2017 and November 2018, in terms of total delayed days (red line) and delayed days by responsible organisation (NHS, social care or both). Over this period, there was considerable variation in the number of delayed days per month, ranging from 835 in March 2018 to 424 in May 2018. During this one-year period, there were a total of 6,996 delayed days in Barnet, of which two-thirds were due to the NHS (67%; n = 4,714), almost a quarter were due to social care (24%; n = 1,650) and the remaining 9% were due to both the NHS and social care (n = 632).[56]

Figure 6.10: Delayed Transfer of Care (DTOC) in Barnet, number of delayed days per month, by responsible organisation, December 2017 – November 2018

Source: NHS England, based on Unify 2 data.

In 2017 /18, there were a total of 1.98 million delayed days across England due to DTOCs, which was an average of 5,420 per day. Nationally, the number of delayed transfers rose between 2013 and late 2016, but has fallen since early 2017. Despite this, DTOCs remain a substantial problem, with many factors contributing to delays. In addition to the growing demand placed on health and social care due to an ageing population and the increasing prevalence of long term conditions and co-morbidities within the population, DTOCs can be due to a range of factors including; the availability of nursing and residential home placements, funding, patient / family choice, delays in assessments and arranging care packages, disputes and the need for further non-acute NHS care. Addressing delayed transfers therefore remains a complex and challenging problem for health and social care at both a national and local level.[57]

[53] NHS England (2018). Why not home? Why not today? Monthly Delayed Transfers of Care Situation Report. Principles, Definitions and Guidance, November 2018. Available at:https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2018/11/Monthly-Delayed-Transfers-of-Care-Situation-Report-Principles-Definitions-and-Guidance.pdf

[54] Kings Fund (2018). Delayed transfers of care: a quick guide. Available at:https://www.kingsfund.org.uk/publications/delayed-transfers-care-quick-guide#how-are-they-measured

[55] NHS England (2018). Better Care Fund: quarterly performance report 2018/19. Quarter 2 data collection and performance report 2018/19 (July – September 2018). Available at:https://www.england.nhs.uk/publication/better-care-fund-quarterly-performance-report-2018-19/ 

[56] NHS England (2019). Delayed Transfers of Care. Available at:https://www.england.nhs.uk/statistics/statistical-work-areas/delayed-transfers-of-care/

[57] Baker, C. (2018). House of Commons Library briefing paper (number 7281, 1 October 2018). NHS Key Statistics: England, October 2018. Available at: http://researchbriefings.files.parliament.uk/documents/CBP-7281/CBP-7281.pdf

6.6 Residential care

Between 2015/16 and 2017/18, the number of people in Barnet in nursing care increased from 387 to 419, a rise of 8%. Only 14% of these people were categorised as Elderly Mentally Infirm (EMI), requiring specialised care within the nursing home for mental frailty, including dementia. A similar proportion of people living in residential homes in Barnet also received EMI care. Over this period, the number of adults in Barnet living in residential homes fell from 1,160 to 1,001, a decrease of 14%. Given the substantial increases in the older population of Barnet in the years to 2030, these figures may change markedly in the coming years.[58]

Activities of daily living include; bathing, dressing/undressing, taking medicines and washing hands and face. Where older people are unable to manage at least one of these self-care activities on their own, there is a clear need for assistance, whether through residential care or supporting the person to continue living independently. During 2019, the number of older people (aged 65+) in Barnet who need help with at least one self-care activity is predicted to be around 16,500 during 2019, the 2nd highest of all the London boroughs. Only Bromley has a higher number of older people requiring assistance with their self-care, based on this measure (see Figure 6.11). Between 2019 and 2035, the number of older people in Barnet who need help with at least one self-care activity is projected to rise from 16,521 to 24,980, an increase of 51% over that period.  [59]

Figure 6.11: Number of older people (aged 65+) who need help with at least one self-care activity, London boroughs, 2019

Source: POPPI

[58] London Borough of Barnet (2019). Dementia JSNA. [Based on data from the Adult Social Care department].

[59] Projecting Older People Population Information System (POPPI, 2018). People aged 65 and over who need help with at least one self-care activity, by age and gender, projected to 2035. Available at: http://www.poppi.org.uk/

[60] Projecting Older People Population Information System (POPPI, 2016). Living in a care home. People aged 65 and over living in a care home with or without nursing by local authority / non-local authority, by age, projected to 2035. Available at: http://www.poppi.org.uk/

6.7 Urgent Care

When people in Barnet need urgent medical attention that does not require A&E attendance, they can attend urgent care centres in Barnet, Royal Free or Chase Farm hospitals, or alternatively walk-in centres in Finchley, Cricklewood or Edgware. At these locations, they can receive treatment for illnesses and injuries that are urgent, but not life threatening, such as broken bones, scalds, bites and stings, minor eye and head injuries as well as sprains and strains.[61]

At present, there is a wide and often confusing variety of treatment options available for patients requiring urgent, but not life-threatening care. These options include; walk-in centres, urgent care centres and minor injury units. So, people often attend A&E departments inappropriately, with up to three million people coming to A&E each year who could be treated effectively in other parts of the urgent care system. This pattern of attendance puts unnecessary pressure on A&E and to address this, units called “urgent treatment centres” are being introduced across the NHS. These units are GP led, open every day for 12 hours and designed to diagnose and treat many of the ailments usually dealt with by A&E departments.[62] 

In future, urgent treatment centres will encompass current minor injury units, walk in centres, GP led health centres and similar facilities currently providing urgent care.[63] By the end of 2019, all of these urgent care options will be called “urgent treatment centres” (UTCs) and will be accessible through GP or NHS 111 referral or alternatively by just turning up and walking in.[64]

In 2017, Barnet, Camden, Enfield, Haringey and Islington CCGs came together to form “North Central London CCGs (NCL)” to put the provision of health and social care services in North London on a more sustainable footing, through closer working with the main providers and the five local authorities. An important part of this work has been the joint, collaborative commissioning of all urgent care services (including NHS 111 and GP Out of Hours (OOH)) across the five CCGs.[65]

Within the North Central London CCG partnership, Barnet has been one of the first areas nationally to launch the new integrated urgent care model. This model includes enhanced mental health liaison services, telephone access for staff to urgent advice from a clinical expert and the facilitation of a more effective return home for hospital patients through agreed standards of working and working more closely with social care.[66]

[61] NHS Barnet Clinical Commissioning Group (Barnet CCG, 2019). Urgent care and walk-in centres.

[62] NHS England (2018). Urgent treatment centres. Available at: https://www.england.nhs.uk/urgent-emergency-care/urgent-treatment-centres/

[63] NHS England (2017). Urgent Treatment Centres – Principles and Standards, July 2017. Available at:https://www.england.nhs.uk/wp-content/uploads/2017/07/urgent-treatment-centres–principles-standards.pdf

[64] NHS (2018). When to visit an urgent care centre (walk-in centre or minor injury unit). Available at:https://www.nhs.uk/using-the-nhs/nhs-services/urgent-and-emergency-care/when-to-visit-an-urgent-care-centre/

[65] NHS Barnet Clinical Commissioning Group (Barnet CCG, 2019). North Central London CCGs (NCL).

[66]   NHS Barnet Clinical Commissioning Group (Barnet CCG, 2018). Barnet CCG: Annual Report and Accounts, 2017-2018.