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26th September 2007 Developing our Picture of Health

This is a joint briefing from the “A Picture of Health” project, on behalf of both Primary Care Organisations and Hospital Trusts in outer South East London.

The “A Picture of Health” project’s aim is to improve the quality, safety and patient experience of NHS services. This can only be achieved through a major change in how services are delivered, bringing care nearer to patients’ homes where possible, but also concentrating specialist hospital services together to achieve better results for our patients.

The “A Picture of Health” project is led by Bromley, Greenwich and Lewisham Primary Care Trusts and Bexley Care Trust.

We have already listened to local people’s view on health services, which has resulted in the “people’s priorities” for service development. To get this type of change right and secure public support, we have put our doctors, nurses and midwives at the centre of planning how services should be structured. Special project work streams were established to make this happen.

Over the summer, doctors, nurses, surgeons, midwives and professions allied to from the four outer South East London hospitals have been researching and debating how they would structure services to make them better. At the same time, doctors and nurses who work in the community have also been considering how services can be developed to treat more people nearer to home, to keep them healthy and with less of a need to be admitted into hospital.

The hospital element of these discussions came together on the 25th September with an all day event, where there was a high level of collaboration and agreement on the major models of care, over and above organisational boundaries. The clinical advice and recommendations from this event will be handed over to the “A Picture of Health” project as one part of the process of developing options for future consultation. No decisions have yet been made, and any proposed changes will be subject to formal public consultation.

Further steps required to develop the options for change include:

1 Web version 1. Receiving a similar piece of work from community based doctors and nurses, ensuring the two models can fit together seamlessly, and that there are robust plans to care for people in the community or in their own homes. 2. Analysing in detail these emerging models in light of potential “constraints”, such as whether there is enough space to provide bigger, more specialist units.

We will also need to check whether there is enough capacity to see current numbers of patients and with the projected growth in population, the changing needs for the future.

Analysis will also be done to ensure that the new models can be delivered within our existing budget.

3. Running a workshop for members of the public to debate and assess how the new services might affect patient access and experience. This will inform the final options brought forward for public consultation, along with the results of the extensive programme of public meetings held over the past year.

4. In October, there will be a thorough clinical review of the reasons for change and options by the National Clinical Advisory Team, led by Professor Sir George Alberti, National Clinical Director for Emergency Access. The review will assess the options for clinical safety, and will engage with doctors, nurses and midwives at all levels in hospitals and the community to provide further assurance that change can be delivered. Professor Sir George Alberti also plans to meet with MPs and the Joint Overview and Scrutiny Committee.

Once these steps have been completed, the emerging options can be considered by a Joint Board of Primary Care Trusts, who will decide which options go forward for a full three month public consultation.

What are the recommendations from the hospital clinicians?

Peter Luce (Medical Director at Lewisham Hospital), David Robson (Medical Director at Queen Elizabeth Hospital), Roger Smith (Medical Director at Queen Mary’s Sidcup) and David Trew (Medical Director at Bromley Hospitals) said yesterday:

“We have looked at the best way to provide hospital services for the whole population. We have not been talking about which site provides which service, but rather how we can best meet the hospital needs of the 1 million people in the area as a whole. There is a high level of consensus amongst colleagues about the recommendations we are making. It has taken a lot of work to get this far, and everyone is very excited about the opportunity for those who deliver the service to help shape a healthcare system which can better care for our patients in the future”

The following recommendations have been made to the PCTs from the Medical Directors: (further detail on each workstream will be published on the project website on 1/10/07)

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• The current situation cannot be sustained, as it will fail to meet new legislation and guidelines, designed to promote safer and higher quality care

• There was a high level of consensus that a move towards two hospitals would be preferred to deliver maximum benefits in terms of improving patient care. However, a three hospital option would also be workable and deliver benefits for our population. It was recognised that this was advice from the hospital clinicians to the PCTs, and not a final decision.

• Maternity, Paediatrics and neonatal (led by Roger Smith) – Our preferred recommendation would be a service with two units, two paediatric units, two co-located midwifery led birthing units, plus a greater promotion of choice of home births, and two neonatal units. There would be an emphasis on delivering more outpatient and maternity care from a greater range of sites in the community. A three unit approach would also be possible, but there would be fewer benefits in terms of improving patient care. On the other two sites, there would be ante natal and post natal care, obstetric scanning including midwifery led antenatal care and obstetric antenatal clinics.

• Emergency Care, A&E and Specialist Medicine (led by David Robson) – Our preferred option would be for two full major A&E units, supporting full medical services. We appreciated that there may be constraints, which would need to be worked through in order to decide whether two or three sites would be put forward as the final recommendation to PCTs.

In order to enable this change in care, we agreed that more detailed work needs to be undertaken with community services to ensure that more patients could be seen in the community. All four sites should maintain access to urgent care services (which would provide service to a majority of current A&E patients). Depending on condition, as is the case currently, patients would be transferred to specialist centres.”

• and Critical Care (led by David Trew) – Our group recommendation was overall for two major sites. This would consist of two emergency surgery services with full A&E, supported by level 3 (which is most high level) Intensive Care Units.

They recommended two planned (elective) in-patient sites, one to be supported by intensive care and up to four day surgery (non complex) units with 23 hour services (these are units which support a one- night stay). We also recommended four outpatients departments with diagnostics and endoscopy, with further moves to support hospital at home, which would enable patients to get home earlier.

In Trauma and Orthopaedics, two sites were recommended for emergency surgery, with potentially one site for orthopaedic inpatient elective work (with high dependency backup) and up to four sites for day surgery.

Very complex work should be done on a major acute site. 3 Web version

In terms of Critical Care, the group agreed they would be able to support a two site or three site model with highest level (level 3) intensive care units.

• Clinical Support/ (led by Peter Luce) – Clinical support services will be configured to support whatever the preferred options are for the main medical and surgical preferences.

What happens next?

Simon Robbins, Senior Responsible Officer for the A Picture of Health Project said, “I would like to thank all colleagues who have participated with such enthusiasm in developing this innovative work. I would like to offer assurances that we will continue to move at a pace which enable us to rapidly make the changes necessary to secure excellent services that are both clinically and financially sound. This advice gives PCTs a range of options, with clear recommendations on the preferred approach from the hospital perspective. I would like to re-iterate that we not planning to close any sites and that under any scenario, NHS services will remain on all four sites, but they may look different to now”.

We are committed to the following actions in order to sustain our current services, and enable us to rapidly make the changes necessary to secure a stable clinical platform and affordable services:

28/9/07 The “A Picture of Health” project board will receive the advice. Work can then take place to check the recommended configurations against a series of constraints: for example, whether there is enough room in the present buildings to accommodate consolidated services, or is further investment required?

1/10/07 Hospital recommendations are published on the project website

October The National Clinical Advisory team (NCAT) review the project. Consultation on proposals for service change will not begin before NCAT has reported on its review. At that point, a Joint Committee of the PCTs will decide whether to proceed with the consultation at the same time that the PCTs will be consulting on the models of care recommended in Healthcare for London: A Framework for Action. Assuming the decision is to proceed, we will ensure there is appropriate consistency between the two consultations.

Following the review, consultation dates will be confirmed, and we will keep you updated about all developments, via the project newsletter and website (www.apictureofhealth.nhs.uk)

Any changes that significantly affect staff's terms and conditions will be subject to formal consultation 4