Trust Headquarters
Queens Park Hospital
Blackburn
Lancashire
BB2 3HH
Telephone: 01254 293678
Email: [email protected]
[email protected]
Our Ref:
Your Ref:
VPB/DH
31 October 2006
Emma Wilkinson
Principal Scrutiny Officer
Joint LCC & BwD Overview & Scrutiny Committee
Lancashire County Council
PO Box 78
County Hall
PRESTON
PR1 8XJ
Paul Conlon
Principal Scrutiny Officer
Joint LCC & BwD Overview & Scrutiny Committee
Democratic Services Department
Blackburn Town Hall
BLACKBURN
BB1 7DY
Dear Emma & Paul
Meeting Patients’ Needs – East Lancashire’s Public Consultation on healthcare
services – Joint Lancashire & Blackburn with Darwen Overview & Scrutiny
Committee Meeting on 7 November 2006
1
Introduction
Thank you for receiving Professor Sir George Alberti at the meeting on 12 October
2006 and for reconvening the committee promptly. The following is a briefing for the
committee members in advance of our presentation on 7 November 2006. Both this
paper and the presentation on the day are designed to address some of the issues
raised during the meeting on 12 October and broadly include:
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Process to date
Why we want to change clinical systems
Additional detail regarding the paediatric services
Obstetric services
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 Urgent Care Centres and delivering more care closer to home
 Paramedic emergency services
 Collaboration between health and social services
2
Process
The committee members received a detailed report on the process for this
consultation on the 27 June 2006, and via the report from Salford University, so this
section will be somewhat abridged.
The Boards of the partner organisations approved the ‘Case for Change’ document
which illustrated the benefits of reconfiguration in terms of clinical outcomes, financial
stability and sustainability of services.
The Health Economy Steering Group (HESG) commissioned a widespread review of
all acute services across East Lancashire and asked each service to generate a ‘care
stream’ report. The reports made it clear that some of the 5 original options were not
clinically or financially viable and hence a decision was made to reduce to 2 Service
Models – these were consulted upon.
The formal public consultation period ran for 16 weeks from 21 March 2006 to 10
July 2006 and over 7800 contacts were made with 1913 responses coming in.
Salford University analysed the responses and found that 36.6% of responders
choose neither service model A or B, the HESG made it clear that no change was not
an option. However, of those who voted for A or B the overall response favoured B.
On inspection the difference of votes between Service Model A & B is only 113.
Given such marginal differences by public responders the Operational Group felt that
the public responses had little impact on deciding for A or B (i.e. it cannot be used as
a sole independent indicative factor).
The Joint PCT Committee met on 21 September 2006 and unanimously voted to
adopt Service Model A. Their decision was accompanied by a number of
recommendations which were outlined in a paper previously distributed to members.
The National Lead for Emergency Care Access Professor Sir George Alberti kindly
visited East Lancashire to analyse the service models at the request of your
members and he submitted his feedback to you on the 12 October 2006.
This briefing and the presentation to the committee on the 7 November is our last
chance to resolve any concerns locally and hence avoid what is potentially a lengthy
external review by the independent reconfiguration panel.
3
Why we are seeking to change the clinical models in East Lancashire
The Case for Change document has been shared previously and the committee has
previously written to express understanding of that case, however, it is perhaps
useful to quickly recap the position here.
3.1
We wish to provide safer, higher quality services which are sustainable for a
decade and beyond to the whole population of East Lancashire. A key development
in delivering this ambition is to separate our emergency inpatients from most of our
elective surgery patients.
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The consequence of admitting emergency patients into a hospital which also cares
for elective inpatients is that the emergencies take priority – this has major ‘knock-on’
effects:
 We currently cancel too many operations (up to 20 patients a week at times)
 Waiting times are too long in many specialties and
 Some patients are cared for on wards which are not established for their
condition e.g. patients with medical problems cared for on surgical wards
 Hospital acquired infection rates are higher when elective pre-planned
patients are cared for in the same environment as emergency patients
By separating emergency inpatients from elective inpatients we expect to see
dramatic improvements in these areas. Other expected beneficial effects are that
we can;
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Increase theatre utilisation
Reduce the length of hospital stay
Simplify the processes for investigations & diagnostic services
Develop more opportunities for research and development within the
emergency care and elective surgical fields and
 Build up our teaching and training capabilities.
Further, there is a growing national trend for senior doctors to specialise in specific
areas of surgery or medicine, which enables them to develop their skills and
expertise. This is known as sub-specialisation and evidence shows that it produces
better results for patients. Too many elective services are currently provided outside
East Lancashire, such as some paediatric surgery to Manchester and some
specialist cancer surgery to Preston. We want to retain and indeed increase the
range of services in East Lancashire and to do this we need our senior doctors to
sub-specialise. In order that they do enough procedures to retain their experience,
many of the Royal Colleges suggest that a population base of approximately 500,000
is needed to do this; the population of East Lancashire is approximate to this. The
centralisation of level 3 neonatology and obstetrics will also benefit from the greater
population base from which the patients are drawn.
3.2
To summarise the financial rationale, the Trust will achieve financial balance
by 2008 but carries considerable risk of non-achievement, however once financial
balance is achieved the process is required to start again. Implementation of the
reconfiguration will help mitigate the risk of the delivery of the financial recovery plan
and enables the Trust to maintain a sustainable service into the future.
The Trust financial recovery plan was prepared in advance of the clinical services
review and is a standalone document. The risk of non-delivery is considerable; the
clinical services review does three things, namely;
 Facilitates the delivery of high quality services
 Mitigates risk of not delivering the financial recovery plan
 Enables sustainability
The Financial Recovery Plan facilitates the delivery of high quality services by;
 Positioning the Trust so that it is able to support the clinical services with their
ambitions to continually develop and become leaders in their fields
 Creating an environment for attracting the best doctors, nurses and other
therapists and staff
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 Enabling the Trust to have freedom to develop a service locally that currently
is provided out of area
It mitigates risk by;
 Delivery of planned activity in a managed way.
 Enables more effective management of medical staffing budget. Reductions
in locum medical staffing expenditure is a key component of the recovery plan
 Enables more effective use of theatres
 Enabling medical rotas to be planned more effectively
The financial recovery plan brings the trust into financial balance by 2007/08,
however beyond 2007/08 the Trust will be required to manage the impact of;
 Working Time Directive for medical staff
 Reduction in the elective tariff as the impact of independent sector drives
down cost and Foundation Trusts become more competitive
 Loss of transitional support for PFI schemes
 The need to create resources from service change due to significant
reduction growth funding for the NHS
3.3
The NHS is facing a number of pressures for change including system reform,
shortages in key staff, advances in healthcare and technology. This means current
configuration of services across the NHS is not sustainable or fit for the future.
Over the past twenty years the average age of the population of East Lancashire has
been increasing and this trend will continue for at least the next fifteen years.
Although people are living longer they are not remaining healthy. On average for
every 2 years of increased lifespan, one year is a healthy year of life and one is a
year of ill-health.
The net result of these changes is a population with increasing health needs and a
reduced number of people aged 16-45 that are able to provide a community support
base. It is clear that the existing pattern of services is not appropriate for the
changing population and it is unlikely to be sustainable in the future because of a
shortage of the skilled workforce necessary. This factor contributes to our case for
change.
In acknowledging these pressures, critical choices have to be made. Do we ‘wait
and see’ how the environment changes or do we proactively engage with our public
about reconfiguring their healthcare. We also believe that doing nothing will result in
the loss of services delivered locally in East Lancashire. This is why we have
designed the proposals being put before you, which were produced by the clinical
and management staff together.
No change is also not an option because of the reforms facing us including the
introduction of ‘Choice;’ ‘Payment by Results’ and the imminent new labour laws from
the European Commission which limits the hours further our medical staff can work
each week.
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4
Some additional details regarding the paediatric services
The Overarching Paediatric Service Model for East Lancashire as previously
described will comprise of:
 Inpatient paediatrics centralised onto the Royal Blackburn site
 Neonatal Intensive Care Unit centralised onto the Burnley General site
 Children’s Observation & Assessment Units on both main sites in Burnley &
Blackburn – the options for the operations of the BGH unit is currently being
assessed (see below)
 Day case surgery on both main hospital sites
 Outpatient services on both main hospital sites
 Improved Children’s Hospital @ Home Service across the footprint of East
Lancashire
 An Urgent Care Centre at the BGH site receiving minor injuries and ailments
(which must be able to safely stabilise the unexpected serious pathologies
which self present)
The senior clinicians (Doctors and Nurses) are central to determining the
requirements for paediatric care in Burnley. The main determining factors are;
 Demand for non-elective paediatric care via GP’s & the proposed Urgent
Care centres
 Medical staffing rotas based on above (and to an extent the RN capacity)
 Chosen service models e.g. Consultants / Nurse clinicians / junior doctors
input etc based on above
We know that there will be a ‘walk-in’ facility seeing adults and children with minor
injuries & illnesses. Equally we can expect some of those patients who walk-in to
need stabilisation and transfer to the emergency hospital in Blackburn, bypassing the
BGH COAU.
A number of options are being assessed:
Option 1 – 24 / 7 COAU at Burnley General Hospital
The COAU operates 24 hours per day / 7 days per week
Maximum expected LOS is approximately 12 hours (usually much less)
Option 2 – 9am to 6pm COAU at Burnley General Hospital
The COAU operates during office hours 7 days per week
Maximum expected LOS is approximately 12 hours (usually much less)
Option 3 – 10am to 11pm COAU at Burnley General Hospital
The COAU operates from 10 am until 11pm 7 days per week – this correlates with
the maximum shift allowed under new EWTD’s.
Maximum expected LOS is approximately 12 hours (usually much less)
The department is currently analysing the impact each of these service options would
have on the basis of a) travelling for families and b) the medical staffing
requirements.
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5
Maternity Services
The National Institute for Health and Clinical Excellence (NICE) published its draft
guidance on intrapartum care for consultation on the 23rd June 20061. There has
been media interest in the guidance statements on place of birth, specifically
regarding perinatal mortality. The document begins with the ‘Key priorities for
implementation: planning place of birth’:
‘Women should be offered the choice of planning birth at home, in a
midwifery-led unit or a consultant-led unit. Before making their choice, women
should be informed of the potential risks and benefits of each birth setting’
Amongst the long list of risks and benefits of birth in consultant led units, at home,
and in standalone or alongside birthing centres, the document goes on to state:
‘there may be a lower risk of perinatal mortality when care is delivered in a consultant
led unit’.
The evidence statement to support this is as follows:
‘There is poor quality evidence on maternal and infant outcomes for standalone
midwifery-led units. When compared with planned birth in consultant-led units, the
available data show a reduction in analgesia use with an increase in vaginal birth and
intact perineum rates.
Women are more satisfied with their experience of childbirth in stand alone midwifery
units. However, perinatal mortality may be higher than in consultant-led units, even
when taking into consideration the poor quality of the evidence and extrapolation
from healthcare settings in different countries.’
This statement has been graded D2, the lowest level of evidence. The evidence is
based on one study from Norway, where the geography and organisation of
maternity care differs from the UK. Because of the paucity of evidence, our Medical
Director (an Obstetrician) suspects that there will be an abundance of feedback to
NICE on this, however mild the statement is. The document gives detailed guidance
on clinical governance structures including agreed criteria for women planning to give
birth in each setting.
1
Intrapartum care: care of healthy women and their babies during childbirth
National Collaborating Centre for Women’s and Children’s Health
Commissioned by the National Institute for Health and Clinical Excellence
Final Draft for Consultation
23 June 2006 – 29 August 2006
2
D
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Evidence level 3 or 4, or
Extrapolated evidence from studies rated as 2+, or
Formal consensus
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6
Care Closer to peoples homes
The government White Paper ‘Our Health, Our Care, Our Say’ signals the shift of
services from hospital to community settings and our public consultation reflects this
strategy.
Both Burnley General Hospital and The Royal Blackburn Hospital have a future but
the old Victorian estate is inappropriate, we have numerous new premises built or
being built across the towns and parishes of East Lancashire. Discussions are
progressing regarding the Rossendale Hospital Project.
We currently know that many of our services which we currently run out of the two
DGH’s can safely and rightly be taken into premises closer to the people e.g.
dermatology, sexual health, musculoskeletal triage, cardiac & stroke rehabilitation
and many more.
Another example of this principle is the current and proposed use of our Emergency
Departments. The vast majority of unscheduled care is important, yet minor in
clinical severity and the development of Urgent Care Centres across a number of
sites in East Lancashire is proposed. The BGH site will run a 24/7 service as will the
one at Blackburn, others will operate to strategic times of peak demand.
We have previously written to the committee about the types of patients and the
numbers involved, yet it is worth reiterating that we expect the UCC’s to take over
85% of the current workload that goes to the A&E departments.
7
Emergency Paramedic Service
The ambulance service has a shift system where a paramedic is assigned on every
vehicle. There are occasions during sickness that lead to double technician crews on
vehicles but these are backed up by ‘floating’ paramedic rapid response vehicles on
the M65 – the current position is that approximately 90% of ambulances have a
paramedic on the vehicle. The proposals outlined for East Lancashire are to be
implemented over the medium to long term and this allows for additional paramedic
training to achieve the 100% paramedics on ambulances that we desire.
With regard to ambulance responses times in East Lancashire, vehicles are moved
around the county using a system of ‘dynamic deployment’ today, which essentially
means the control centre in Preston manipulate the location of vehicles using satellite
navigation and the vehicles are moved according to demand. East Lancashire has
48-49 vehicles during daytime peak times and around 35 during the night when it is
quieter. Under the proposals, with 2 extra vehicles, the same system will apply and
we expect response times to be maintained.
It is worth noting again that treatment in ambulances has progressed over the last 15
years – clot busting drugs are given either in home or in ambulances for patients with
a heart attack. They carry more quality equipment, a wider spectrum of drugs than in
years gone by and their skills are increasing all the time. With regard to the “golden
hour” – a lot of what is needed for the patient during that hour can be achieved in the
ambulance.
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8
Collaboration with other statutory partners, voluntary sector etc
The Meeting Patients Needs is a whole systems transformational change project
which impacts upon the patient pathways in primary, secondary, tertiary and social
care sectors. It is deliberately focussed on the hospitals sector in the main; however
it is the first step towards a wider transformation of how we deliver services across
the health and social care systems.
We recognise that the patient does not necessarily care which organisation is
delivering a service; only that it works in smooth alignment to the other organisations
and that when a patient or client is referred between practitioners the interface is
untroubled. Equally our staff wish for an interface that they can rely on, which helps
them move patients between services without fear of endless letters / paperwork and
phone calls.
The leadership of the implementation programme for Meeting Patients Needs will
comprise of senior officers from all health & social care sectors, and the project
streams will include practitioners from each sector. Concerns previously raised by
committee members and put to us as recommendations by the Joint PCT Committee
will be managed and mitigated by having such a collaborative approach.
9
Conclusion
We submit to you that Service Model A is deliverable, and has been designed by
clinicians who are dissatisfied with the current health and social care system and
have an outstanding ambition to create the best service for their patients. These
same clinicians (as well as Professor Sir George Alberti) argue that the clinical
outcomes of their patients will be better if we adopt the proposed Service Model.
We have justifiable reasons for expecting the medium to longer term financial
position in East Lancashire to be improved as a result and we can equally justify a
serious risk to the future of many local services if we do not change.
The opportunity to transform a public sector business such as ours is rarely found,
the alignment of better clinical outcomes, better value for money and a more secure
and sustainable future exists within this proposal. The implementation of the
proposed changes will be monitored closely over time to ensure we are getting the
benefits we seek, and we shall only move a service once clinically safe to do so.
Yours Sincerely
Val Bertenshaw / Declan Harte
On behalf of the - Meeting Patients Needs Operational Group
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