Worcestershire hospitals fit for tomorrow

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1 WHY WE NEED TO CHANGE OUR HOSPITAL SERVICES IN WORCESTERSHIRE Worcestershire hospitals fit for tomorrow Engagement Phase Hospital services in Worcestershire are changing 1

2 2 Hospital services in Worcestershire are changing

3 Contents Worcestershire hospitals fit for tomorrow Foreword... 5 A personal message from the Chairman of the Joint Services Review... 7 Map of hospitals... 8 Facts about local organisations... 9 Part one: Why we need to change Living longer getting older Innovation and workforce Making our funding go further Part two: Reviewing our healthcare services Our review principles The four clinical care pathways Women and children s services Planned care Emergency care Part Three: No decision about me without me your chance to get involved The decision making process timetable Potential clinical models for our future hospital services The short-listing criteria The local clinicians who are leading this process Glossary Ways you can get involved and have your say Tell us what you think form Elderly care Hospital services in Worcestershire are changing 3

4 4 Hospital services in Worcestershire are changing You can find out more about what this will mean for you and your family in this publication. We hope that you will take the opportunity to get involved. We give you our promise that we will take your views into account and we will all work together to give Worcestershire residents hospital services to be proud of.

5 Worcestershire hospitals fit for tomorrow A message from local clinical leaders The NHS is changing all across the country, including here in Worcestershire. The way the NHS runs, with much of our healthcare provided by hospitals, has changed little since it was first set up back in But we, the people who use it, have changed. We are older. We are living with more long term medical conditions, and some of us are leading less healthy lifestyles than we used to. As a result demand for healthcare is rising. New and more effective drugs, treatments and technologies are also improving our overall health and wellbeing. At the same time we are facing a growing pressure on funding right across the public sector. We need to make the same amount of money stretch much further. The challenge to us, as clinical leaders of your local NHS, is to make sure that we can continue to provide you with high quality healthcare that is safe, accessible, helps keep people healthy and, importantly, is affordable. We know this is what you rightly expect from your local health services. We know that with demand for healthcare rising every year, the way we currently organise health services in our acute hospitals across the county is going to be increasingly difficult to deliver in the future. This will have an effect on our promise that you will receive high quality care. Put simply, we need to make the money we have go further. Our future challenge is to stretch the same level of funding we have now to meet increasing demands for healthcare services and to provide you with new and expensive technologies and drugs. If we don t take action now to make sure we are spending our money in the most effective way, it is quite possible that people won t be able to get the treatment and care they need or that the quality and safety of our healthcare services will deteriorate. This is not a position we want to find ourselves in. We already have much to be proud of. We believe the dedication of our staff is second to none and we can boast about hitting most of our quality targets like making sure you get cancer treatment when you need it. Over the last few months, local doctors, nurses and other health and social care professionals have been discussing our health service challenges. We have been looking at how our hospital services might be provided differently and how to decide which choices should be considered further to make sure you and your family can continue to receive safe, high quality care. We must take the opportunity now to think about how we make best use of our resources so that healthcare services are available far into the future. This will mean some difficult conversations and taking some hard decisions over the coming months. Hospital services in Worcestershire are changing 5

6 We want to involve you in these conversations immediately. To begin with we are inviting you, Worcestershire s public, patients and health service users, to give us your views on our initial ideas. We will be starting the debate with you between 14 June and 9 July This may seem like a short period of time, but it is only the start of the process. No changes will be made before a full public consultation takes place during the autumn. We need your help. We need your opinions and ideas to help us make the best decision. We particularly want to know if you agree with the criteria we intend to use to decide which clinical models should be considered further. We don t yet know what the best answer is, but we do know that staying as we are is not an option. Dr. Anthony Kelly General Practitioner Chair of Worcestershire Clinical Senate Dr. Charles Ashton Medical Director Worcestershire Acute Hospitals NHS Trust This message and the commitments within it are endorsed by your local NHS Chief Executives Eamonn Kelly NHS Worcestershire Penny Venables Worcestershire Acute Hospitals NHS Trust Sarah Dugan Worcestershire Health and Care Trust You can find out more about what this will mean for you and your family in this publication. We hope that you will take the opportunity to get involved. We give you our promise that we will take your views into account and we will all work together to give Worcestershire residents hospital services to be proud of. 6 Hospital services in Worcestershire are changing

7 A personal message from the Chairman of the Joint Services Review (JSR) We all know the NHS is largely protected from the public spending cuts which are being felt so painfully elsewhere. However we also know that it is facing a major challenge as the nation gets older and requires more healthcare and as better but more expensive new technologies and drugs are developed. Nationally this has been described as the 20billion productivity challenge. The requirement to provide better healthcare services to more people for the same money is challenging every part of the NHS, not least here in Worcestershire. It is absolutely clear, as you will see from this document, that this challenge cannot be met without radical changes to the way that services are provided in this county. As a layman (I like to think of myself as Joe Public within the local NHS), I am absolutely convinced that the key to any such changes lies within our acute hospitals and so this is surely the place to start. After all acute hospital care accounts for more than half of the total NHS expenditure in Worcestershire. However acute care will not be the end of the story - every other service, including GPs, community services, social care will no doubt have to change to complement any changes in acute care. This is why we have initiated this Joint Services Review. Joint means it involves all the various organisations and different types of professionals who help to provide your healthcare. We undertook to keep you, the public, informed of progress throughout the duration of this study with eventually proper formal consultation on the final options. This document is setting out why things need to change and to share the early work of our doctors and nurses. We believe that all service re-designs should be lead by clinicians, (i.e. hospital consultants, GPs, community specialists, nurses, senior social care workers etc all working together) As a result we have asked our senior clinicians to start by looking at the clinical quality and safety issues involved in the configuration of our three hospitals. So far both the hospital costs and the detailed implications for other services have deliberately been kept until later. We recognise that this may lead to a situation where we are now telling you about clinical models developed in this early stage but which we have already deemed to not meet future quality standards or that we subsequently dismiss as unachievable. We know that we thereby risk exciting you unnecessarily (in both directions). I ask you to accept this as the inevitable down-side of our openness and desire to involve you at every stage. Dr. Bryan G. Smith OBE Non Executive Chairman of the Joint Services Review Steering Committee Hospital services in Worcestershire are changing 7

8 M54 M6 Toll M40 Kidderminster Hospital and Treatment Centre M5 Kidderminster Hospital and Treatment Centre Alexandra Hospital (Redditch) Tenbury Community Hospital Prince of Wales Community Hospital M42 M40 Worcestershire Royal Hospital M5 Alexandra Hospital (Redditch) M40 Malvern Community Hospital M50 Pershore Community Hospital Evesham Community Hospital Worcestershire Royal Hospital M40 M5 8 Hospital services in Worcestershire are changing

9 FACTS ABOUT LOCAL ORGANISATIONS NHS Worcestershire (PCT) NHS Worcestershire (Primary Care Trust) is currently the main commissioner of health services across the county. It holds the purse strings for the county s healthcare budget of approximately 900million. The PCT will be replaced by Clinical Commissioning Groups in April Worcestershire Acute Hospitals NHS Trust (WAHT) WAHT provides acute hospital services from three main sites: the Alexandra Hospital in Redditch, Kidderminster Hospital and Treatment Centre, and Worcestershire Royal Hospital. Each year WAHT carries out over 95,000 planned and emergency operations, sees more than 140,000 A&E attendances and around 500,000 outpatient appointments, including appointments with consultants or specialist nurses, diagnostic tests such as X-rays and minor surgical procedures. WAHT employs 5,700 staff and has an annual turnover of more than 320 million. Worcestershire Health and Care Trust (WHCT) WHCT provides community health services (including community hospitals, district nursing, therapies, children s services and minor injuries units) and mental health and learning disability services across the county. Worcestershire Health and Care Trust employs 4,500 staff and has an annual turnover of 167 million. Worcestershire Clinical Commissioning Groups (CCGs) Clinical Commissioning Groups are being established across the country to take the place of Primary Care Trusts. Led by local GPs, CCGs are the bodies that will hold health budgets and take on the responsibility for buying health services to meet the needs of local communities. CCGs will become fully functional in April Worcestershire has three CCGs Redditch and Bromsgrove CCG, South Worcestershire CCG and Wyre Forest CCG. Hospital services in Worcestershire are changing 9

10 The work to change our local healthcare services in Worcestershire is only just starting. No decisions have yet been taken. We made a commitment to all Worcestershire residents in February 2012 that we would involve you throughout the process, including when our clinical reference group had developed views on possible models of care for the future. We want to start hearing your views now, in advance of a formal public consultation exercise taking place this autumn. Part one: Why we need to change Introduction The NHS in Worcestershire is responsible for planning and providing healthcare services for 570,000 people across the county. It holds a budget of around 900million each year. NHS Worcestershire and its local Clinical Commissioning Groups, Worcestershire Acute Hospitals NHS Trust and Worcestershire Health and Care Trust are working together to look at ways some of your hospital services must change to make sure we can continue providing you with the best possible care in the future. We plan to launch a public consultation on the preferred option in September This will give you an opportunity to have a say in how hospital services will be provided in the future. This publication explains why we need to take these steps and also how you can have your say at this early stage. Living longer, getting older Here in Worcestershire, we re all living longer. The older we get, the more likely we are to develop conditions related to age such as Type 2 diabetes which can lead to complications like kidney failure, blindness and heart disease. Worcestershire s elderly population is growing at more than 3%, which is above the national average. In other words, we have a greater 10 Hospital services in Worcestershire are changing

11 number of older people than other parts of England. With every passing year more people are requiring more healthcare. This is creating a challenge for our healthcare services as the older people are, the more likely they are to require treatment and stays in hospital. We know that we can do more to prevent illness and provide good healthcare for older people outside of hospital. We want to help them stay active, well and living in their own homes for as long as possible. To do this, we are starting to think differently about the sort of healthcare services we need. By redistributing some of the money we spend on hospital services, we will be able to invest more in disease prevention and community services and help people stay healthy or treat their conditions in their own homes or local area. We know that this is what people want....a health strategy centred on high-cost hospitals will be inefficient and unaffordable compared to one focused on prevention and supporting individual well-being in the community. Department of Health: Our Health, Our Care, Our Say The health of people in Worcestershire is generally better than in other parts of England but we still have significant problems. We are living less healthy lifestyles. A quarter of our adults are obese and a further 40% are overweight. Obesity and age are high risk factors for developing long term medical conditions so we might expect to see an increase in serious health conditions like heart disease. There were also 9,000 hospital admissions for alcohol related ill-health and we see nearly 900 deaths from smoking each year. Many patients want to have more care and treatment nearer to home. Too many people are admitted who shouldn t be, and stay longer than they should or want to. Some care is better carried out in the community, or in specialist centres further from home. National Voices, a coalition of more than 200 health and social care charities As a health service, we ve known for a while now that we can t continue to provide such high levels of hospital care the Department of Health recognised this in 2006.This means it s time to turn our attention towards helping people reduce their risk of developing medical conditions whilst providing more effective treatment for those who already have them. In this way, we can fully expect to see more people being able to live active and healthy lives for much longer, stay closer to their loved ones and reduce the amount of time they need to spend in hospital care. Hospital services in Worcestershire are changing 11

12 Taking advantage of innovation in treatment and workforce We know that doing things differently can provide better results for people. Our healthcare system, and hence our patients, benefits from new technologies, medicines and ways of treating people that are better and faster. For example, we have recently updated our MRI scanner in Kidderminster. Patients are now benefiting from faster scanning times and higher quality images, helping doctors to deliver better, safer results. Over the last few years across England as a whole, we ve seen some significantly improved results for conditions like stroke, heart disease and trauma care because we ve changed the way we organise services. Round the clock care for heart attack patients. Worcestershire Acute Hospitals NHS Trust Board has recently approved plans to commence a 24 hours a day, seven days a week service for heart attack patients. When this is introduced we expect the service to provide potentially lifesaving treatment to an extra patients per year. It also means that patients across the county will be able to receive care closer to home and no longer need to travel to Birmingham, Coventry or Wolverhampton for treatment. 12 Hospital services in Worcestershire are changing

13 In many of these cases, care has moved away from smaller local hospitals to bigger hospitals with specialist teams. There are many advantages to bigger hospital teams. For example: They can provide expert teams with more specialised, highly experienced members of staff on board. They can draw on more resource across the hospital. They can afford to invest in and make more use of expensive new equipment. They attract and keep the best staff. For all of these reasons and more, they are generally safer places to be than smaller hospitals. We all take it for granted that our services are safe. But safe, high quality services require investment in the right equipment and treatments, and in attracting and retaining the best staff. A recent study by Imperial College in London showed that more patients die because of inadequate staffing in NHS hospitals than in road accidents. The gold standard would be to have consultants present at hospital sites 24 hours a day, seven days a week, but this is proving unachievable in many hospitals because of the way services are currently organised. shows a clear link between the volume and expertise of a service and the quality of care. For example, smaller hospitals often find it hard to recruit experienced paediatric consultants as some hospitals do not see enough sick children to maintain a consultant service. However, research shows that a seriously ill child has a better chance of survival if they are brought into the hospital care of a paediatric consultant. This is also true for seriously ill new-born babies and maternity care. Many of these Royal College clinical guidelines are becoming the new standard for care used by health watchdogs such as the Care Quality Commission to measure our services. In Worcestershire we are struggling to appoint sufficient doctors in some specialties to cover medical rotas across all of our sites and have to overcome this with locum doctors, temporary staff provided by agencies or, in some cases, through establishing consultant-only services. This problem will continue to worsen with the way care is currently organised. We want to make sure that we organise our services in such a way that we can avoid these problems in the future, and will be able to meet the standards set. If we don t do this we will be failing in our duty to put patients first and provide high quality health care. We cannot find ourselves in that position. There is an increasing body of evidence coming from research done by expert bodies such as the medical Royal Colleges that Hospital services in Worcestershire are changing 13

14 Making our funding go further...if the NHS is to cope with the financial pressures it is going to face under any government without resorting to indiscriminate and damaging service and staffing cuts, large-scale planned service redesign and reconfiguration based on clinical evidence will have to be at the heart of the strategy. Letter to the Guardian, April 2010 signed by the: Academy of Medical Royal Colleges, Royal College of Physicians, Royal College General Practitioners, NHS Confederation, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics & Child Health, Royal College of Psychiatrists, Royal College of Anaesthetists, Royal College of Physicians, Royal College of Radiologists, Royal College of Ophthalmologists, Faculty of Public Health Medicine, Faculty of Pharmaceutical Medicine, Faculty of Occupational Health We can expect the financial challenge to grow in the longer term as national economic circumstances demand increasingly better value from the public sector. We are committed to offering the population of Worcestershire a value for money service that operates within its budget. To do this and make the savings required means a major change in thinking about the way we provide healthcare. For example, we know that if we keep hospital services as they are we would have to increase the number of hospital consultants which would increase our spend by at least another 3.5 million just to meet future quality standards. There simply isn t the funding available to do this. One way of finding the savings we need is to look at the way we have organised our hospital services, which operate across multiple sites. Across the country we spend a lot of money - about 10% of the entire healthcare budget - on buildings which we don t use very efficiently. In many cases we only use them about half the time they re available to us if we think of this as a seven day a week, 24 hour a day service. We could be spending potentially about half this money on providing patient services rather than on heating, lighting, grounds maintenance and all the other maintenance issues that come with buildings. Although these are the national figures, we would not expect Worcestershire to differ and it is an issue we need to address. 14 Hospital services in Worcestershire are changing

15 The country is seeing a growing demand for healthcare as a result of an ageing population, the rise in obesity, inflation and the introduction of new drugs and technologies. However the funding available to the NHS for healthcare will remain largely static over the next three years. 900 MILLION 900 MILLION 900 MILLION 2012/ / / / /14 As a result there is a growing gap between demand for healthcare and the funding available, which for Worcestershire is 900 million for 2012/13. Nationally this gap will reach 20 billion by 2014/15. In Worcestershire it will reach 200 million. The local NHS needs to make savings totalling 200 million across all services. The acute hospital s share of this is 50 million. 2014/ / / /15 Hospital services in Worcestershire are changing 15

16 WORCESTERSHIRE AT A GLANCE The population of Worcestershire has increased at an average rate of 1,700 per year since By 2026 the estimated population will be 586, % of Worcester s population live in major urban areas such as Worcester, Redditch and Kidderminster. The remaining 40% are dispersed across a wide area of more than 650 square miles. Worcestershire has a population of approximately 570,000 people. Life expectancy at birth is 82.7 years for Worcestershire women and 78.8 years for men compared to 82.3 and 78.3 nationally. This has risen by about three years over the last decade. Nearly 150,000 people are treated in the county s two A&E departments every year. There are almost 500,000 outpatient appointments and over 100,000 operations carried out across the main hospital sites. 16 Hospital services in Worcestershire are changing

17 The population is older than England as a whole with 19% aged over 65 compared to 16% nationally. The number of people over 65 is expected to rise by 30,000 over the next 20 years. There at least 6,000 people aged 65 or over living with cancer in the county. The incidence of cancer is increasing, as are survival rates, so the number of older people living with cancer is set to rise considerably. The Worcestershire NHS budget for 2012/13 is 900million. This will remain fairly static over the next four years. The local NHS needs to make savings of around 200 million over the next four years to address the emerging gap between the demand for healthcare and the funding available. Hospital services in Worcestershire are changing 17

18 Part two: Reviewing our healthcare services The NHS in Worcestershire our Joint Services Review Health service change is happening all across the country. We have started to look at our health services in Worcestershire to make sure that safe, high quality healthcare is available now and into the future so that Worcestershire doesn t lag behind the rest of the NHS. Reviewing our services to make sure that we can provide you with high quality healthcare is not new to Worcestershire. Over the last seven years we have assessed a wide range of services and issues. We have looked at the evidence to make sure that we are improving and providing your healthcare services in the best and most affordable way. These reviews have been carried out in consultation with patients and public. They have resulted in us spending our money more efficiently whilst improving areas such as the way patients travel through our health systems and the way we use our operating theatres. Our patient satisfaction surveys tell us that there is a good level of satisfaction across the county, with 73% of our patients saying they would recommend the Trust to friends and family, but we know we could be doing better still. For example, all patients who arrive at our emergency care departments and need to be admitted to the hospital should have to wait no longer than four hours. We are not hitting this target even though we have 18 Hospital services in Worcestershire are changing

19 increased our staff. We are committed to improving the care and experience for people who have urgent health care needs. The main focus of this review is our acute hospital services - those services that are provided from the Alexandra, Kidderminster and Worcestershire Royal Hospitals and specific acute services that are provided at some of the community hospitals. However the five Community Hospitals situated in Bromsgrove, Evesham, Pershore, Malvern and Tenbury whilst not specifically included in the review, play a key role in helping reduce the demand on our acute hospitals. Therefore in parallel to this work, we are also looking at services across the wider health and care system, particularly the links between acute hospitals, community services and GP surgeries so that we can understand how we might be able to deliver more integrated care and provide the right care in the right place at the right time. voluntary and community sector to help us design a good way of engaging, involving and communicating with you which ensures you are able to effectively influence the review and to scrutinise our process as we go along. Our work is on-going and whilst we will invite your views at all stages of the process, we specifically wish to have your views at this early stage when our ideas are developing and before we go to a formal consultation process and come to any decisions later in the year. As clinicians we been looking at all the available evidence and have developed some new and different ideas about providing healthcare services that are affordable, high quality and will meet both the current and future needs of our local population. We have looked at how some of our current acute services might be organised with these new approaches. As a result we have developed new clinical models of acute care. You can find out more about these proposed clinical models in Part Three of this document on page 31. We have also been holding focus groups with patients, service users and the general public to make sure we include your views at the start of our work and as it progresses. We have set up an independent body of representatives from the private, public, Hospital services in Worcestershire are changing 19

20 Clinically led: Expert clinicians including consultants, doctors, nurses and professions allied to medicine from the acute trust, primary care, health and care trust and social care are leading the development of options for how our services might change. We also have a clinical senate in place which is responsible for making clinical recommendations to the review steering group. Our clinical reference group will consider all the feedback it receives and include it in its work wherever possible. Rigorous: We will fully assess all our options for health service changes to check what effect they are likely to have on the quality, safety and productivity of services. This approach will include an external independent clinical peer review. OUR REVIEW PRINCIPLES Our review is being governed by five key principles Open and transparent: We are working to an involvement and communication strategy that will make sure the challenges facing our services currently and the options we are considering for change are made public and comply with both best practice and legal standards. Inclusive: We want to listen to you. We want to give everyone the opportunity to contribute, comment and be involved in the development and assessment of options for any service changes. We have set up an independent Stakeholder Reference Board to ensure that the views of public, patients and service users are fed into the decision making process. The Board will check that the review gives sufficient opportunity for everyone to influence the development and consideration of options for service change. Managed and resourced: Our review will have a single governance structure and decision-making process and will follow best practice ways of working. The partner organisations will make sure it has adequate managerial and clinical resources available to do the job properly. 20 Hospital services in Worcestershire are changing

21 How and who decides the preferred option Our review is clinically led. This means it is led by doctors and other healthcare professionals. The ideas we come up with will be collated into clinical models and widely shared and discussed before any final decision is taken. Wherever possible, clinicians will be involved in the discussions that take place with the public. Three important issues have been taken into account as a key part of the process: An obligation to our local communities to deliver safe, high quality care locally. This promise will be impossible to deliver consistently in the coming years without changing our services. This is especially true given the pressures on the budgets of all public sector organisations. Increasing the scale of health services to enable clinicians to organise themselves around larger, more senior and more specialised clinical teams with access to the latest and best equipment, technology and treatment. This will provide better quality of care for patients and better health results. Local and national health plans, strategies and policies that clearly show high quality care requires a shift of NHS resources from acute hospitals towards primary and preventative care. This means better organisation of healthcare to deliver improved health and healthcare outcomes for the wider population. Local doctors, nurses and other healthcare and social care professionals, along with public and patient representatives have come up with a set of criteria that will be used to assess and compare the different clinical models. The models will also be subject to a financial assessment to determine whether they are affordable. This work will produce a short-list of options. These options will be looked at by a panel of independent clinical experts so we can be sure we have considered all the right clinical evidence and made the right choices about future clinical models of healthcare. A three month formal public consultation is planned for the autumn. This will provide Worcestershire residents with the opportunity to have your say on the proposed option(s). Then a final decision on the preferred option will be taken by the Board of NHS Worcestershire following guidance from the Worcestershire Clinical Senate and the Boards of local NHS organisations. Hospital services in Worcestershire are changing 21

22 What does high quality care look like? As clinicians we believe high quality care requires that: When necessary, care is delivered by a clinical team with real expertise in the relevant specialty or sub-specialty. this level of care across multiple sites and with recruitment in some services already difficult, the situation is likely to become more challenging. There is national recognition that smaller hospitals will find it increasingly difficult to meet these and other minimum quality requirements in the future. You are seen by a specialist in your condition on the same day or within 12 hours of being admitted, including at the weekend. Your diagnostic and other tests are completed on the latest equipment and delivered to you rapidly. Your surgery is performed by experienced teams who perform the same operation on a regular basis, and emergency surgery is only performed with the back up of critical care teams. Your care at night time and weekends is from qualified staff, and to the same standard as during the day. Specialist children s doctors and nurses are available with the right facilities to care for your sick infant or child. Throughout your labour, midwife and specialist obstetrics care is available as necessary for your clinical needs. WAHT provides this quality of care for most of its services. But as clinicians we know that this promise of high quality care is going to be increasingly difficult to deliver in the future. In many cases, our teams are currently too small to support delivery of 22 Hospital services in Worcestershire are changing

23 The four clinical care pathways Our review has been looking at four key areas where we think we can make changes that will lead to high quality health services being available, accessible and affordable into the long term whilst reducing our costs now. These areas are highlighted below. Elderly Care People in Worcestershire are growing older. An ageing population will lead to significant issues providing care for the elderly across the region if we don t act now. One of the things we need to be better at is working together as an integrated health community and joining up the different health services that elderly people receive. In this way we can expect a consistent standard whether care takes place at the hospital, in a GP or community setting. Currently a large proportion of hospital inpatient services are provided to people over 65. There is increasing evidence from across the country that older people struggle to cope when taken into hospital, particularly when they are admitted under emergency circumstances. The complexity of their conditions means that it takes longer to assess and resolve their problems and that during this time they may become disorientated, less mobile, and find it more difficult to return to their previous level of independence. Where possible we are aiming for care to be provided outside of hospital so that people s independence can be maintained. In many cases this can be achieved by staff from the hospital trust working with colleagues in primary and community care. Where this is not possible we want to ensure that an older person stays in hospital for no longer than absolutely necessary for the best health results. We are building on a good platform. Primary care across Worcestershire is strong and there are good examples to learn from. For instance, in Wyre Forest there has been an increase in the number of terminally-ill patients who have been able to choose to die at home, rather than in hospital. This has happened thanks to the efforts of the joint work of local NHS organisations. Working together, they have focused on integrating care and giving meaningful choice to patients and their families and carers. Examples from elsewhere in the NHS, as well as internationally, show working together across primary, secondary, community and social care, as well as mental health care, improves health results and patient satisfaction. This approach also reduces costs over time. Yet examples of joined up elderly care have not been easy to replicate across the county. Our review is looking at how these issues might be addressed. Hospital services in Worcestershire are changing 23

24 Dr Simon Hellier, Consultant Gastroenterologist and Clinical Director for Medicine at Worcester Royal Hospital, Kidderminster, talks about elderly care services We ve been looking at how Worcestershire currently provides elderly care services and how we might continue to be able to provide them over the next ten to 15 years by using our resources more efficiently. The focus of our work has been on the services provided through the acute hospitals, but we have also been looking more widely across our healthcare community. We want to be able to provide as much care at home or within the community for our elderly residents as possible. Part of this work has been to look at where our hospitals stand in comparison to other similar hospitals across the West Midlands but also across the rest of the country so that we really understand what a good standard looks like and how we need to improve our services where we can within the constraints of our finances. 24 Hospital services in Worcestershire are changing

25 Women and Children s Services Women and children s services is a good example of a service that shows a clear link between the scale of that service, the seniority of its staff and the quality of care patients receive. Consultant cover 24 hours a day, seven days a week is essential for children and maternity services. In Worcester, this would mean needing 10 consultants at the two hospital sites where these services are provided. This would be both impractical and unaffordable. Similar pressures are faced by consultant-led obstetrics. One solution might be to maintain local outpatient and diagnostic services but concentrate emergency services onto one site to ensure that quality and safety can be maintained 24 hours a day. We believe this would develop a centre of excellence for complex and highly specialised care, allowing access to innovative treatment and technology and improving the Trust s ability to recruit and retain the best staff....tell us what you think on pages Dr Angus Thomson talks about women and children s services Quality and safety is everything. I want to know that when my team and I have finished operating that we have done a good, safe job. I want to know that I don t have to worry about my patients because I can be confident that they will be well looked after overnight and that they ll be fit to go home in the morning. I want to know that my hospital s patients are getting the very best treatment that they could get anywhere in the country. As clinicians, we should always strive to provide that safety and level of quality. I believe we need to look at centralising specialist services. In a county the size of Worcester we can only have one or two specialist surgeons looking after women and children s health. I would rather that women travel to see these specialists and have their operations in a place which will provide them with the best results. Hospital services in Worcestershire are changing 25

26 Dr Mr David Angus Law Thomson, talks about Consultant planned Obstetrician/Gynaecologist care and Clinical Director Obstetrics/Gynaecology trust-wide, talks about Planned women care and covers children s all of those services healthcare services where you sit down with your GP and decide what it is that needs to Quality happen and and safety can be is everything. planned for. I want This might to know include that when appointments my team and I with have a finished specialist, operating having a that planned we have operation done performed, a good, safe or job. some I want tests to or know x-ray that taken, I don t for example. have to worry about my patients because I can be confident that they will These be well services looked don t after always overnight fit well and together that they ll for be the fit patient, to go so home this in is a the good morning. opportunity I want for to us know to sit that down my hospital s and discuss what patients would are work getting well the for very the best patient treatment and help that them they have could a get smooth anywhere and high in the quality country. experience. This might include quicker access to services, or easier processes to get appointments As clinicians, we with should specialists. always strive to provide that safety and level of quality. I believe we need to look at centralising There specialist is a services. real challenge In a county here the for us. size I think of Worcester we all recognise we that can only unless have we one want or to two pay specialist more taxes surgeons there looking is only so after much money women to and go children s round and health. this has I would to pay rather for our that NHS. women This means travel to we see have these to do specialists things in and a better have their and more operations efficient in a way place and which planning will provide is a really them important with the way best of results. doing this. 26 Hospital services in Worcestershire are changing

27 Planned Care Planned care is care that is scheduled for you to have your treatment or surgery. At the moment, planned care services are delivered at all three acute hospital sites. This may have benefits of access and convenience for the public, but it is harder to provide a consistent and high quality service for patients, particularly for surgical services. One solution might be to locate all inpatient surgical services onto a single site with outpatients being provided more locally across the county, including potentially in community settings and GP surgeries. The concentration of services means the necessary expertise and resources and best technology are in one place and national guidance on ensuring access to outpatient services is met. These benefits are particularly important for patients with cancer or suspected cancer. Around 80-90% of surgery is routine. There are real benefits in trying to separate out routine surgery from more complex and higher risk surgery. For example, there is far less risk of operations being cancelled or disrupted by the need to accommodate emergency patients at short notice and the risk of healthcare associated cross infection can also be reduced. Dr David Law talks about planned care Planned care covers all of those healthcare services where you sit down with your GP and decide what it is that needs to happen and can be planned for. This might include appointments with a specialist, having a planned operation performed, or some tests or x-ray taken, for example. These services don t always fit well together for the patient, so this is a good opportunity for us to sit down and discuss what would work well for the patient and help them have a smooth and high quality experience. This might include quicker access to services, or easier processes to get appointments with specialists. There is a real challenge here for us. I think we all recognise that unless we want to pay more taxes there is only so much money to go round and this has to pay for our NHS. This means we have to do things in a better and more efficient way and planning is a really important way of doing this....tell us what you think on pages Hospital services in Worcestershire are changing 27

28 Dr David Law, GP and Clinical Commissioner on Redditch and Bromsgrove Clinical Commissioning Group, talks about planned care Planned care covers all of those healthcare services where you sit down with your GP and decide what it is that needs to happen and can be planned for. This might include appointments with a specialist, having a planned operation performed, or some tests or x-ray taken, for example. These services don t always fit well together for the patient, so this is a good opportunity for us to sit down and discuss what would work well for the patient and help them have a smooth and high quality experience. This might include quicker access to services, or easier processes to get appointments with specialists. There is a real challenge here for us. I think we all recognise that unless we want to pay more taxes there is only so much money to go round and this has to pay for our NHS. This means we have to do things in a better and more efficient way and planning is a really important way of doing this. 28 Hospital services in Worcestershire are changing

29 Emergency Care Over the last years evidence has shown that patients get better treatment and are more likely to survive an emergency if they are looked after by a more experienced doctor. Historically more experienced doctors have largely been available in hospitals during weekdays, with more junior doctors covering the rest of the week, albeit with consultants on call. In order to ensure the highest quality care 24 hours a day, seven days a week, many hospitals are now moving towards having consultants in charge of patients care for far more of the time. This would require at least full time consultants per site and for a range of emergency services including A&E, emergency surgery and critical care. It will not be possible to provide this level of care at both Worcester and Redditch hospitals with the existing workforces. Even if more doctors could be recruited, they would not gain enough experience to maintain their specialist skills from the workload at one site only. We know that the healthcare needs of some of the people who come to A&E can be met in other clinical settings. Receiving care in primary care settings can also be more appropriate and cost effective for some patients. We need to rethink how emergency services are provided not only across the Trust but also across the county. Our challenge is to set out alternate ways of organising services to deliver better results for our patients which will ensure high quality, safe and affordable care for the future. Dr Chris Hetherington talks about emergency care We ve been looking at the evidence we have to understand how our emergency care services might be best provided. This has included looking at where our services are delivered and the workforce that we need to support them. We need to look at what the demands are and where they are across the county and look at the workforce we have and the facilities we have and decide how to put them to the best possible use to provide high quality and safe emergency care. Quality is the top of the agenda but we will have to make some hard decisions. The services as they currently stand are difficult to maintain from a quality and safety perspective but also from a staffing position. The decision we need to make is how to maintain a safe and effective emergency care service for the whole county. What will this look like? Will it be accessible? How do we maintain the standards that our patients expect and deserve? We might have to move our services around the county....tell us what you think on pages Hospital services in Worcestershire are changing 29

30 Dr Chris Hetherington, Consultant in Emergency Medicine and Clinical Director Emergency Medicine Trust-wide, talks about emergency care We ve been looking at the evidence we have to understand how our emergency care services might be best provided. This has included looking at where our services are delivered and the workforce that we need to support them. We need to look at what the demands are and where they are across the county and look at the workforce we have and the facilities we have and decide how to put them to the best possible use to provide high quality and safe emergency care. Quality is top of the agenda but we will have to make some hard decisions. The services as they currently stand are difficult to maintain from a quality and safety perspective but also from a staffing position. The decision we need to make is how to maintain a safe and effective emergency care service for the whole county. What will this look like? Will it be accessible? How do we maintain the standards that our patients expect and deserve? We might have to move our services around the county. 30 Hospital services in Worcestershire are changing

31 Part Three: No decision about me without me your chance to get involved No decisions have been made at this stage. But we are developing our proposals and want to hear what you think. Your views and opinions will help to design services that will best meet the county s needs and provide you with real choice and convenience as we move further towards providing health care on a seven day week, 24 hour day basis. This section of the document looks at our ideas and proposed models so far and describes how you can have your say. Short listing and decision making Over the last few months, local doctors, nurses and other health and social care professionals have come up with a range of ideas and models for how hospital services might be provided to meet the healthcare and financial challenges of the future. Those deemed safe and achievable are being tested against a set of criteria which have been developed in conjunction with public and patient representatives. The models will also be subject to a financial assessment to make sure they are affordable.this process will be used to decide which models offer the best way of organising hospital services for the future or what we call our short list of options. The final option(s) will be presented to you for public consultation in the autumn. The results of our public consultation will go forward to the Board of NHS Worcestershire. This Board, advised by the doctors and nurses leading this process, along with the Boards of the Acute Hospitals Trust and Worcestershire Health and Care Trust, will make the decision on the preferred option. Hospital services in Worcestershire are changing 31

32 The Decision Making Process Timetable Local doctors, nurses and other health and social care professionals have produced a range of models for how hospital services might be provided. April and May 2012 Along with public and patient representatives we have also produced a set of criteria that will be used to assess and compare the different models. Models and short-listing criteria presented to the public, patients and service users. June 2012 Those models thought by local doctors and nurses to be safe and achievable will be short-listed in partnership with public and patient representatives. July 2012 The short-list of options is considered in further detail. August 2012 The option (s) are presented at public consultation. October, November and December 2012 Response from the public consultation considered. December 2012 Decision on preferred option. December Hospital services in Worcestershire are changing

33 Potential clinical models for our future hospital services Model Description This section describes the clinical models that we have developed so far. All of the clinical models are presented below for your information along with a commentary from local doctors and nurses about their strengths and weaknesses. This section highlights which of the clinical models we believe to be safe and achievable at the start of our process and those that we have discounted as unsafe or not able to meet future minimum quality standards and our reasons. Those deemed safe and achievable clinically will go forward to the short listing phase. In every clinical model we have stated our commitment to providing facilities to treat minor injuries, outpatients and some diagnostic services in the local area where these services are currently located, to ensure local access is maintained as far as possible. We would like to hear what you think about these clinical models. You can find a feedback questionnaire at the end of the publication. A No change (Three sites - fully staffed medical rotas) B Two acute hospital sites (each with full A&E dept) Women and children s services brought together onto one site One hospital treatment centre with MIU C One acute hospital site (with a full A&E dept) One acute site with Urgent Care Centre One hospital treatment centre with MIU DOne acute hospital site (with a full A&E dept) One hospital site providing planned surgery One hospital treatment centre (includes planned surgery) with MIU E One acute hospital site (with a full A&E dept) One hospital site providing planned surgery with MIU F One acute hospital site (with a full A&E dept) Hospital services in Worcestershire are changing 33

34 Model A No change This model would maintain all hospital services as they are on the three sites. Doctors and nurses believe that in order to meet minimum quality standards going forward we would have to expand the team of specialists onto each of the acute hospital sites across a range of specialities. Even if the funding was made available - which it is not, we do not believe that we will be able to recruit the doctors with the specialist skills; we also believe that these doctors would not gain enough experience to maintain their specialist skills from the workload at one site only. As clinical leaders we believe this model will not meet future minimum quality standards even if additional funding were available.... Model B Two Acute hospital sites (each with full A&E dept) Women and children s services brought together onto one site One Hospital Treatment Centre WITH MIU This model would maintain hospital services as they are on the three sites, except for bringing all women and children s care together into a single location. This could be done in different ways: One way would be to move complex women and children s care to one site, leaving less complex care and a midwifery led unit at the second site. Alternatively, we could move all women and children s care to a single site. As clinical leaders we do not believe that this model should be considered further. We don t think that we would be able to recruit sufficient children s consultants to cover both sites for the first suggestion to really work. The second way would make it easier to recruit children s consultants but would leave an A&E at the second site without children s consultant cover. This would not be safe because it is likely that children would still be brought to the second site where there would be no properly trained children s consultants to treat them. We believe that both versions would suffer shortages of qualified and experienced consultants in other specialities as with Model A above.... Model C One Acute hospital site (with a full A&E dept) One Acute site with Urgent Care Centre One Hospital Treatment Centre WITH MIU This model would maintain one acute hospital site with a full A&E and trauma services, emergency medicine, women and children s services. This hospital would also have facilities for complex emergency surgery as well as the most complex planned surgery, outpatients and a full range of support services including diagnostics, pharmacy, laboratories, physiotherapy and rehabilitation. A second site would would see and assess 34 Hospital services in Worcestershire are changing

35 adults referred by their GP or brought in by ambulance with urgent but less complex medical problems. It would be able to admit them overnight if necessary. It would also offer an urgent care centre and would see and treat patients with minor injuries. The site would have no emergency surgery facilities. Some patients might need to be transferred to the acute /emergency site for emergency treatment if their condition got worse. The second site would also provide most of the outpatient services and planned surgery, along with the appropriate support services - including some high dependency care, diagnostics and laboratories. There might be the possibility of a Midwifery Led Unit depending upon whether enough experienced midwives could be recruited and there is sufficient demand to make the service affordable. There would be a children s rapid access clinic available during daytime hours which GPs could refer to and which would be supported by a children s community nursing service. This model would help to ensure the quality and safety of women and children s services, and would, in part, address the difficulties in recruiting qualified and experienced consultants in other specialities. Emergency care for the most severely ill patients would be available at a single acute emergency site. Therefore these patients would travel by ambulance to their nearest A&E. This model would require careful planning to ensure patients went to the right site. In this model there would be no change to the Kidderminster Treatment Centre which would continue to offer a Minor Injuries Unit, less complex elective surgery, a rehabilitation ward, outpatients, and support services. At this stage, as clinical leaders we think that this model should be safe and achievable and it should be considered further at the short listing stage.... Model D One Acute hospital site (with a full A&E dept) One Hospital site providing planned surgery with MIU One Hospital Treatment centre (includes planned surgery) with MIU This model would maintain one acute hospital site with full A&E and trauma services, emergency medicine, women and children s services. This hospital would also have facilities for complex emergency surgery as well as the most complex planned surgery, outpatients and a full range of support services including diagnostics, pharmacy, laboratories, physiotherapy and rehabilitation. A second hospital site would change to focus on planned surgery, along with the support services this would need including some high dependency care, diagnostic and laboratory facilities. It would also provide a Minor Injuries Unit and outpatients. There would be no facility to see or assess adults with urgent medical problems and no emergency admissions. There might be the possibility of a Midwifery Led Unit depending upon whether enough experienced midwives could be recruited and there is sufficient demand to make the service affordable. There would be a children s rapid access clinic available during daytime hours which GPs could refer to and which would be supported by a children s community nursing service. This model would help to ensure the quality and safety of women and children s services and of emergency care across the whole of Worcestershire. It Hospital services in Worcestershire are changing 35

36 would, in part, address the difficulties in recruiting qualified and experienced consultants. Such a model would enable us to establish a centre of excellence for providing planned surgery at one of the hospitals. The separation of emergency care from most planned surgery should reduce disruption of planned surgery due to emergency admissions, and mean that the numbers of cancelled operations are dramatically reduced. This would improve patients experience of care and as we move to seven day a week working would also provide patients with greater choice and convenience. Emergency care for the most severely ill patients would be provided at a single acute / emergency site. Therefore these patients would travel by ambulance to their nearest A&E. In this model there would be no change to the Kidderminster Treatment Centre which would continue to offer a Minor Injuries Unit, less complex elective surgery, a rehabilitation ward and outpatients, and support services. At this stage, as clinical leaders we think that this model should be safe and achievable and should be considered further at the short listing stage.... Model E One Acute hospital site (with a full A&E dept) One Hospital site providing planned surgery WITH MIU This model would maintain one acute hospital site with full A&E and trauma services, emergency medicine, women s and children s services, and facilities for complex emergency surgery as well as the most complex planned surgery, outpatients and a full range of support services including diagnostics, pharmacy, laboratories, physiotherapy and rehabilitation. A second hospital site would change to focus on planned surgery, along with the support services this would need including some high dependency care, diagnostic and laboratory facilities. It would also provide a Minor Injuries Unit and outpatients. There would be no facility to see or assess adults with urgent medical problems and no emergency admissions. This model would help to ensure the quality and safety of all services across the county as a whole. It would enable us to establish a centre of excellence for providing planned surgery at one of our hospitals. The separation of emergency care from most planned surgery should reduce the disruption of planned surgery due to emergency admissions, and mean that the numbers of cancelled operations are dramatically reduced. This would improve patients experience of care and as we move to seven day a week working would also provide patients with greater choice and convenience. The model would be supported by a range of new primary care and community services. These services would offer care and treatment closer to home and improve care quality and patient experience. They could also provide care which is better integrated with other local services such as social care and mental health teams. A reduced number of hospital sites will improve recruitment and achievement of the right numbers of consultants to maintain minimum quality standards in all specialities. Emergency care for the most severely ill patients would be via a single emergency hospital site. These patients would travel by ambulance to their nearest A&E. Access to planned surgery would reduce from three sites to two sites. However outpatient and diagnostic services would be available in the three existing towns as at present. There would be increased travelling times for some patients and some where the nearest hospital is outside the county. 36 Hospital services in Worcestershire are changing

37 A Minor Injuries Unit would be maintained in the third town, although not necessarily on the existing site. There might be the possibility of a Midwifery Led Unit depending upon whether enough experienced midwives could be recruited and there is sufficient demand to make the service affordable. There would be a children s rapid access clinic available during daytime hours at the second site and in the third town which GPs could refer to and which would be supported by children s community nursing services. As clinical leaders we think that this model should be safe and achievable and should be considered further at the short listing stage.... Model F One Acute Hospital site (with a full A&E dept) This model would maintain one acute hospital site with full A&E and trauma services, emergency medicine, women and children s services, and facilities for complex emergency surgery as well as planned surgery, outpatients and a full range of support services including diagnostics, pharmacy, laboratories, physiotherapy and rehabilitation. The second and third hospital sites would be closed. A Minor Injuries Unit, outpatient s and diagnostics facility would be maintained in the second and third towns, although not necessarily on the existing hospital sites. There might be the possibility of a Midwifery Led Unit depending upon whether enough experienced midwives could be recruited and there is sufficient demand to make the service affordable. There would be a children s rapid access clinic available during daytime hours in the second and the third towns which GPs could refer to and which would be supported by children s community nursing services. This model would help to ensure the quality and safety of all services across the county as a whole. It would be supported by innovative new primary care and community services which would enable people to receive high quality, integrated care either in or very close to their own homes and communities. From learning elsewhere, the single hospital site model will greatly improve recruitment and achievement of the right numbers of consultants to maintain minimum quality standards in all specialities. Emergency care for the most severely ill patients will be available at the single emergency site. These patients would travel by ambulance to their nearest A&E. This would increase travelling times for some patients and for some this might be to hospitals outside the county. With emergency care and planned surgery on the same site there might continue to be disruption and cancellations of planned surgery due to emergency admissions. However, we would expect that many patients would be able to receive treatment and care through services provided in their own communities which would minimise the need to travel for hospital care. As clinical leaders we think that this model should be safe and achievable and should be considered further at the short listing stage. Hospital services in Worcestershire are changing 37

38 What does this mean for community services? We continue to work together as a group of health professionals to consider the shape of community services which support the acute hospital clinical models. Our aim is to increase the provision of community services in line with the changes to the acute hospital services so you continue to receive safe, high quality care. We are undertaking work in parallel to the review of hospital services which will establish a clear vision and plan for the modernisation of services in the primary and community setting. This aims to deliver better integrated care across the county and includes social care and mental health services. Some of the models allow much greater scope for the development of services in primary care and in the community. This could result in easier local access to high quality care for patients and service users. Health services provided through primary care and in the community can also be developed to integrate better with other local services such as social care and mental health teams. The short-listing criteria As local doctors, nurses and other health and social care professionals, along with public and patient representatives we have developed a set of criteria that will be used at the short-listing stage to assess and compare the different models we ve just described. We have weighted the criteria according to how important we think they are. The clinical models will also be subject to a financial assessment to make sure they are affordable. Criteria 2 below, is related to access and makes reference to travel times. We appreciate this is important for both patients and families. Over coming months once short listing is completed a more detailed piece of work will be undertaken by commissioners to review strategic issues including travel times and transport. We would like your views on the shortlisting criteria. A questionnaire is included to provide feedback. You can also use this form on page 49 to provide us with any other comments about our service review. Your views will be taken into account when finalising the criteria and before applying them to the models. CRITERIA 1 Improved, more sustainable clinical quality We will consider whether the clinical models offer patients a high quality and safe service. A good option would improve the outcomes of care and the satisfaction with care, and would guarantee safety into the future. It would allow patients to take advantage of the latest treatments and technologies. It would also enable greater integration of healthcare between the hospitals and the community, and with social care. In addition it would allow services to innovate and develop in response to the changing needs of local people in the future.... CRITERIA 2 Better access to services for patients and families We will consider whether the clinical models allow good access to services 38 Hospital services in Worcestershire are changing

39 - either at the main hospital sites or through services provided locally. A good option would offer patients choice and convenience, including services in the community where appropriate. It would offer a range of travel options and reduce travel times overall.... CRITERIA 3 Improved strategic fit of services We will consider whether the clinical models allow the NHS to meet the needs of people in Worcestershire as well as the needs of people in other parts of the West Midlands. A good option would provide clear and high quality pathways from local hospital services to highly specialised regional hospital services for our patients. It would also attract patients from other parts of the West Midlands region. In addition the NHS is mindful of the responsibility and opportunity to develop services co-located with other organisations and to contribute to the wider social and economic health of the county. A good option would improve partnerships with other public sector and voluntary sector organisations and local businesses, and allow a range of services to be provided from the same sites.... CRITERIA 4 Meeting training, teaching and human resource needs We will consider whether the clinical models allow the NHS to attract, train and retain skilled staff and volunteers. A good option would offer an attractive working environment for employees and volunteers, with good training, research and development opportunities.... CRITERIA 5 Making more effective use of resources We will consider whether the clinical models allow the NHS to make the best use of resources - including staff and buildings. A good option would allow flexible use of people and property to provide services. It would also improve productivity and reduce overall costs and environmental impact.... CRITERIA 6 Deliverability We will consider whether the clinical models are practical to implement. A good option would be easy and quick to put in place. It would have a positive impact on transport, car parking and other local services. It would also be acceptable to the public, patients, staff and other local organisations.... Hospital services in Worcestershire are changing 39

40 Weighting the criteria Our local clinicians and public and patient representatives think that some of the criteria are more important than others and have weighted them accordingly. This weighting will be applied to the decision making process. Criteria Recommended Weighting 1. Improved, more sustainable clinical quality Better access to services for patients and families Improved strategic fit of services Meeting training, teaching and human resource needs Making more effective use of resources Deliverability Hospital services in Worcestershire are changing

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