A
"EXCELLENCE AS STANDARD" CONFIGURING SERVICES TO ACHIEVE THE BEST PATIENT TREATMENT AND CARE
Briefing for the South Yorkshire Health Scrutiny Meeting on 18 March 2010 and Sheffield City Council Health and Community Care Scrutiny Board Meeting on 19 April 2010
A: INTRODUCTION
This paper has been prepared to facilitate a discussion in the form of a brief presentation followed by a question and answer session for approximately one hour. Mike Richmond, Medical Director and Chris Linacre, Director of Service Development will be present from the Trust. For both meetings officers of Sheffield Primary Care Trust and possibly the North Trent Specialised Services Commissioning Group will be present.
We suggest that the focus of the meeting on 18 March 2010 should be those proposed changes that involve the services delivered by the Trust to the whole North Trent area which are Gastro-Intestinal Surgery, services for heart attacks and other acute Cardiology services, Plastic surgery and elements of Spinal surgery. These are explained below.
The other proposals are more associated with the services provided by the Trust to those who live in or close to Sheffield and therefore rely on the acute and emergency services and should therefore be discussed in more detail at the meeting on 19 April.
B: BACKGROUND
The Trust (STHFT) was formed in 2001 following a merger of the former Central Sheffield University Hospitals and Northern General Hospital NHS Trusts. This followed a major exercise running through the 1990's when the Sheffield Health Authority, with the co- operation of the two Trusts re-aligned many of the clinical services provided in the city in order to achieve optimal patient care and make best use of resources and facilities. Merger saw the Royal Hallamshire (RHH), Weston Park (WPH), Charles Clifford Dental (CCDH), Jessop Maternity Wing (JW) and Northern General (NGH) Hospitals brought under a single NHS Trust and in 2004 a NHS Foundation Trust. As part of this exercise the former Lodge Moor, Nether Edge Hospitals and old Jessop Hospital for Women were closed.
At the end of that process of service realignment there was en element related to the main acute services left unfinished, principally General Medicine and General Surgery. This reflected the major change that had taken place but preserved both direct emergency medical and surgical admissions on both sites following the move to a single A&E department at NGH. This has held constant from 1997 but there is a number of new drivers for change in the NHS that have caused the Trust to propose some further, relatively small changes, that will finalise the exercise. We believe that the time is now right to complete the
1 VERSION : 5 March 10 alignment to further improve the quality and safety of patient care in the Trust and to respond positively to new national initiatives to introduce "gold standards" of care for heart (cardiac), brain (stroke) and emergency care. In addition the role of the Trust as the Cancer Centre for North Trent which includes the whole of South Yorkshire, Bassetlaw and North East Derbyshire has resulted in many specialist cancer services being located in Sheffield and the proposed alignment exercise will, we believe, further improve those services involved. The subject of major trauma is being addressed by the Yorkshire and Humber Strategic Health Authority but is not a part of these proposals.
The proposals under discussion are based on:
1. A clear commitment to retain all clinical services currently available to the public of Sheffield and other areas in North Trent (Doncaster, Rotherham, Barnsley, Chesterfield, Worksop). Indeed the options under discussion seek to give the opportunity to develop appropriate services but in the right place and with the right supporting services/facilities for the very best patient care.
2. Retaining both current hospital complexes, Central Campus including the RHH, WPH, CCDH, JW and the Northern Campus represented by the NGH. The majority of other services will not change and will be considered only in terms of how the impact of the proposed changes would affect them.
3. One decision has been made at this point which is the future of Acute Cardiology services caused by our meeting the requirements of the national strategy for heart attacks. This has seen the phased introduction of a centralised provision of Primary Angioplasty or Primary PCI from the Chesterman Wing at the NGH for the populations of Sheffield, Rotherham, Barnsley, Doncaster, Bassetlaw and shortly Chesterfield.
4. The model for a high standard of Stroke Care has also been finalised and the proposed location for the Acute Service in Sheffield will be the RHH. Currently Stroke care is also provided from the NGH but the national strategy requires acute service provision from a single location. Both these services have been the subject of national and local consultation although the final location of the Stroke service is a part of these proposals.
5. The remaining components of these proposals have been put forward following comprehensive clinical input from staff of Sheffield Teaching Hospitals NHS Foundation Trust (STHFT), consultation with Trust Governors and briefing of Primary Care Trust Commissioners. Further planned consultation will include groups representative of service users and with staff. The proposals are the subject of continuing detailed analysis and for that reason and for the reason of wishing to take account of consultation, are not finalised.
This paper sets out in summary form the reasons for proposing the reconfiguration (alignment) of services and the benefits and risks that we see arising from it. This complex and interdependent series of changes have been shared with the Trust’s Governors who have been supportive of the work done to date. The history and current service configuration is covered briefly below but can be explained further at the meetings.
C: RATIONALE FOR CHANGE
• To provide "optimal patient centred care" taking into account "best practice", clinical guidance and patient experience. • To ensure that the provision of care will be as safe as possible.
2 VERSION : 5 March 10 • Having determined the structure to deliver optimal patient care we need to ensure it is delivered in the most efficient and cost effective way.
• To ensure that services are as accessible as possible consistent with safety and sustainability.
D: DRIVERS FOR CHANGE
• The review by Lord Darzi which introduced "gold standard" care for those suffering a heart attack or stroke.
• Safest arrangements for major surgery.
• Minimising the impact of the European Working Time Directive (since August 2009 doctors can only work a maximum of 48hrs per week) which can be challenging when providing medical staff for two sites admitting direct emergency care and the duplication of other supporting services that make this possible.
• Ensuring maximum efficiency from our operating theatres to ensure we can meet the growing demand for elective surgery without compromising access by urgent or emergency surgery.
• Ensuring the most efficient use of our beds to provide "the right care in the right place by the right specialist first time".
• Ensuring that the balance of activity between elective (planned) activity and emergency unplanned activity is maintained in such a way that we can cope with high emergency demands without causing detriment to planned operations or care which will limit as far as possible the cancellation of operations.
• Meeting the need for additional Intermediate and continuing health and social care. Not only could discharge be more effective with appropriate capacity for these patients, we believe that many admissions could be avoided if these services are designed with an enhanced clinical capability.
• Responding to the anticipated slowing of growth in NHS resources which will require greater efficiencies to maintain existing services delivered at the same high standard.
E: EXISTING CONFIGURATION OF SERVICES
The service alignment referred to in the introduction that started in the mid 1990’s has resulted in the following distribution:
Central Campus
• Maternity and Women's services - Jessop Wing • Head & Neck services (ENT, Ophthalmology, Neuro-services, Oral and Maxillo- Facial surgery) - RHH • Breast services - RHH • Upper Gastro Intestinal surgery - RHH • Haematology - RHH • Urology - RHH
3 VERSION : 5 March 10 • Dermatology - RHH • Infectious Diseases and Tropical medicine - RHH • Clinical and Laboratory Haematology - RHH • Oncology/Radiotherapy - WPH • Dental - CCDH
Northern Campus • A&E - NGH • Cardiology and Cardio-thoracic surgery - specialist unit (Chesterman) at the NGH • Spinal Injuries - specialist unit at the NGH • Vascular surgery - NGH • Orthopaedics - NGH • Metabolic bone services - NGH • Acute and End Stage Renal services - NGH • Lower Gastro Intestinal (Colorectal) surgery – NGH
Both Campuses • Acute and General Surgery - RHH and NGH • Acute General Medicine - NGH and RHH • General Critical Care - NGH and RHH including a new state of the art £23m Critical Care Unit at the NGH • Laboratory and Clinical Imaging services - RHH, NGH, WPH
F: THE CHANGES THAT ARE PROPOSED
Very few of the service described above are involved directly with these proposals but we are careful to be aware of and deal with the impact that the changes may have on all services. For this reason the Programme Board membership is drawn from all the major services, and also includes Patient Governors. The services directly affected are set out below and these are explained in some detail in the paragraphs that follow:
• Surgical services comprising Gastro Intestinal surgery, Acute and General surgery, elements of Plastic surgery, elements of Spinal surgery • Stroke • Acute Cardiology • Acute General Medicine, • Intermediate and Continuing Care
A Programme Board led by the Medical Director and Director of Service Development comprising Consultants, Nurses and other healthcare professionals and their senior managers is now moving to the detailed planning associated with the following proposals with a potential implementation date between September and November 2010.
The logistics associated with these proposals internally to the Trust is complex but the impact on service users will be minimal in the sense that following the proposed changes, the same range and scope of services will be available from the Trust but some from a different hospital than currently.
4 VERSION : 5 March 10
Detailed planning of these changes is now in process. The overall number of beds available will be higher but we plan to staff the same number as at present. The additional beds will provide solutions for single-sex wards or bays on wards, space for decanting to support essential maintenance and major ward refurbishment without loss of service and the potential to staff more beds to manage pressures temporarily in response to winter pressures.
There may be wards available at the conclusion of these proposals caused by a reducing length of stay for the acute services and following the opening of innovative facilities such as Operating Theatre Admissions Units and Post-Operative surgical units on both campuses and medical/surgical assessment units at the NGH. In addition, a dedicated Hand Unit will shortly be under construction which will further increase the proportion of day-case surgery for emergency and elective patients. The available wards are likely to be at the RHH and are allowing us to explore an option for Hospital step-down/continuing care facilities, a concept that is covered in more detail in sub-section 5 below.
1. Surgical Services
- Unification of Gastro Intestinal (GI) inpatient surgery at the NGH. This will move the current Upper GI surgery to NGH from RHH.
- The amount of GI surgery remaining at the RHH may be small. However, outpatient clinics and endoscopy lists for both upper and lower GI surgery will be available at the RHH.
- Plans to relocate the inpatient Plastic Surgical reconstructive surgery from NGH to RHH will enhance the Breast, Head and Neck and major Skin reconstructive surgery by unifying the Plastic Surgeons with their collaborating surgeons in the same location. This will also assist with balancing the operating theatre impact.
- Construction of a new Hand Unit at the NGH is scheduled for completion in December 2010
- Unification of Emergency General Surgery at the NGH. Complex inpatient major General Surgical services will be centred at the NGH but a range of ambulatory General Surgery will be available for ease of access at both NGH and RHH.
- Breast, Endocrine, ambulatory (walk in/minor/day case) General Surgical services will be consolidated at the RHH (as now).
- Consideration of a joint Neurosurgical/Orthopaedic elective Spinal Surgery service based at the RHH whilst maintaining and strengthening the spinal trauma service at NGH. This will have the effect of transferring both operating lists and beds from NGH to RHH.
2. Stroke
- Establishment of Hyper-Acute, Acute and post-acute Rehabilitation Stroke Units accessed through one single entry point at RHH for all patients believed to be suffering a stroke. This is in line with the national "gold standard" care pathway recently published.
- Establishment of a network of local hospitals adjacent to and including Sheffield all of which are intending to assessment, imaging and if appropriate, thrombolysis.
5 VERSION : 5 March 10
- Hyper-acute and acute services in one location in each city. For Sheffield we propose that this will be the RHH.
- Network-wide Consultant rota supported by telemedicine and remote access to imaging.
- Appropriate hospital rehabilitation service linked closely with Community Stroke Rehabilitation services to ensure fast flow through the hospital services.
3. Acute Cardiology
- A Gold standard "Heart Attack Centre" has been established at the NGH Chesterman Unit. Primary Percutaneous Coronary Intervention (PPCI) or primary Angioplasty is now in place for patients from Sheffield, Rotherham, Doncaster and Bassetlaw with Chesterfield completing the implementation in March 2010. This is recognised as the optimal patient care for certain types of heart attack as the survival rate is proven to be much greater.
- The small residual service at RHH was closed to direct referrals/attendance from 1 November 2009 when all patients suspected of heart attack have been directed to the centre at NGH which offers the safest and optimal treatment whatever the presenting symptoms reveal. This is in line with national best practice outlined in the Mending Hearts and Brains report and has been required by the Specialised Commissioning Group for North Trent. There will continue to be a Consultant Cardiology presence at the RHH together with outpatient and high dependency services for those patients who require Cardiology support.
4. Acute General Medicine
- From December 2009 a team of 6 Consultant Acute Physicians were in place operating out of 3 Medical Assessment/Admission wards at NGH. One of the wards and four of the Consultants were new. This was a foundation to enable all unselected patients (those not seen by a health professional) and some emergencies referred by an appropriate health professional to be seen, assessed in one location and if necessary admitted from that one location. Emergency admissions referred to the RHH have been and will continue to be seen there in all medical and surgical specialties in that hospital including some General Medical patients but for these latter patients only between Monday to Friday for 12 hours each day. This will make provision for direct admission to RHH for any patient with a previous history there.
- All emergency patients arriving at or referred to NGH will be channelled through the A&E Department followed by a Medical Assessment or Surgical Assessment ward from which they will be discharged, given an urgent outpatient appointment or, if necessary, admitted to a bed under the management of the appropriate Medical or Surgical specialty. We believe that this will improve the patient care, speed up the care pathway and ensure the right patient is treated by the right doctor in the right place without delay. Patients will be referred by the Acute Physicians to the service best placed to progress their care including when appropriate those services at RHH and WPH. Some cross city transfers of stable patients will be necessary. They will be reviewed at their destination
- The location of the main base for each of the main General Medical specialties is still under discussion but the preferred configuration is as follows:
6 VERSION : 5 March 10 o Respiratory (Chest) Medicine – NGH (some elective and specialist Pulmonary Vascular beds at RHH).
o Diabetes and Endocrine Medicine – NGH.
o Gastroenterology – A dedicated acute ward at NGH to take all Gastroenterology emergencies with the elective service based at RHH . o Healthcare for the Elderly – NGH and RHH (Acute take at NGH, rehabilitation at RHH linked to the Stroke service).
o Outpatient clinics, diagnostic facilities and day case admissions for the medical specialties will still be available at the RHH.
5. Intermediate and Continuing Care
Intermediate Care is the service that sits between hospital and patients’ homes and represents that period in the pathway of care that for many can avoid admission to hospital or can speed up their discharge if a hospital admission has been necessary.
Continuing Care is the service that many patients need to meet their health and/or social care needs on a long term or enduring basis that will often follow a period in hospital when an acute crisis will fundamentally change the home circumstances and capability of people to live independently. In the sense of this exercise, both are fundamental to the hospital beds being sufficient to cope with the demands placed upon them by allowing patients to enter the hospital environment for appropriate acute care and then to move on to alternative arrangements, intermediate or continuing care, without delay.
Intermediate Care is a service commissioned by NHS Sheffield (NHSS, the Sheffield Primary Care Trust) and now provided by Sheffield NHS Intermediate Care Partnership (a formal partnership of Sheffield PCT Provider Services, Sheffield Teaching Hospitals, Sheffield Health and Social Care Trust and Serco Health. NHSS has made significant investment in these services over the past two years and the following actions to be taken by NHSS are relevant to these proposals:
o In the year 2008/2009 and 2009/10 an investment of approximately .£5Million recurrently to enhance Community Assessment Rehabilitation Services (CART) in response to continued demand pressure on hospital beds to improve the quality and scope of service to those who are able to return home from hospital or can avoid hospital by a period of home support.
o From 1 April 2010 introduction of the newly commissioned ‘Care in Your Own Bed’ service which was procured competitively and will from that date be provided by Sheffield Intermediate Care Partnership.
o From April 2012 an intention to commission a new single residential facility to replace the current dispersed arrangements. This will provide an environment for those not able to return to their own homes without a further period of rehabilitation. This is currently being prototyped at Beech Hill in Sheffield with a focus on Stroke and Orthopaedic patients. The new facility is expected to be in use from 2012.
Continuing Health Care is the subject of a highly structured assessment process which determines the extent to which a patient requires continuing health care to support a
7 VERSION : 5 March 10 primary health need rather than or in addition to, social care. The assessment process largely takes place in hospital for those people who have been admitted and are awaiting discharge and also in the community generally for those who require continuing support but have not been admitted to hospital. In the sense of this exercise, it is those who are in hospital that are the most relevant. Clearly if the assessment process is long and the introduction of the assessed plan is delayed, then acute hospital beds are being used inappropriately and are not available to those who need acute care. The impact of this has been and continues to be a shortage of hospital capacity for elective or planned care, mostly surgical, which then becomes delayed. NHSS has called together a Continuing Care Strategy Group involving NHSS as a commissioner, Sheffield City Council Social Services both as a commissioner and provider of care, NHSS Provider Services, Sheffield Teaching Hospitals and Sheffield Health and Social Care Trust. This is a relatively new arrangement and amongst other challenges is seeking to address the overall continuing Care capacity in the city.
Within the context of these proposals we are starting to explore the concept of transforming some hospital capacity to hospital based step-down facilities but not managed as part of the acute services. This could be a contributory resource for continuing care capacity within the city. This is made possible as a result of a reducing length of stay of patients who have been admitted for either an acute illness or for planned care. This will also provide, potentially, a much faster solution for any shortage of residential capacity in the city for an increasing number of older people who may require it. It would also remove/reduce the future need for additional capital expenditure and building stock all of which would act against the sustainability agenda facing the NHS.
G: BENEFITS ARISING FROM THE PROPOSALS
The reasons for pursuing these proposals have been set out above in sections C and D but it will be helpful to set out some of the benefits we expect to be realised. In summary these are:
- Major Surgery in the safest place fully supported by Critical Care
- ‘Emergency’ General surgery in one location in which operating lists can be reliably scheduled during the day providing greater safety
- Less transportation across the city of patients requiring major surgery
- Less reliance on sub-contracts with Independent Hospitals as more planned activity takes place in Trust hospitals
- Gold standard service for those suffering from a heart attack or stroke
- Comprehensive medical and surgical assessment of emergency admissions followed by early transfer to the appropriate specialty care for those needing admission
- Further concentration of expertise and facilities for those patients requiring major surgery for cancers of the digestive system
- Further concentration of expertise and facilities for those patients referred to or arriving at hospital as emergencies
8 VERSION : 5 March 10 - Provision of a more comprehensive distribution of outpatient and ambulatory services on both the RHH and NGH sites which will improve access for that part of the care pathway
H: RISKS ARISING FROM THE PROPOSALS
Whilst we expect the benefits set out above to be realised we are aware that all change also brings risks. The Programme Board is currently working in detail on the planning of the proposed changes and is seeking to minimise the likelihood and size of those risks identified.
C C Linacre 5 March 2010
9 VERSION : 5 March 10