Board of Directors Meeting Date: 30 July 2008 Agenda item: 10.2, Part 1 Title: Prepared by: Presented by: Action required: Elaine Hobson, Director of Operations Elaine Hobson, Director of Operations The Board is asked to note the changes that are planned and will be implemented during 2008/09 Monitoring Information Please specify HC standard numbers and tick other boxes as appropriate Healthcare Standards CORE Healthcare Standards DEVELOPMENTAL Standard numbers Standard numbers Monitor Finance Service Development Strategy Performance Management Local Delivery Plan Business Planning Assurance Framework Complaints Equality, diversity, human rights implications assessed Other (please specify) Board Date: 30 July 2008 1 of 5
1. PURPOSE 1.1 This report updates the Trust on the outcome of the review of the clinical and managerial arrangements within the hospital that takes account of changing operational requirements and more equitably distributes managerial responsibilities across the senior management team. 2. BACKGROUND 2.1 The need to enhance managerial resilience to create leaders for the future is pressing throughout the NHS. Cohorts of managers are reaching a level of seniority that results in them being in a position to move on from director posts or to look to retirement. Restricted national investment in the development of health service managers has resulted in a limited number of people being identified as ready for very senior positions. Within the Trust we have had a stable senior management team for some time, but have concerns about the depth of suitable candidates to replace them in the future without a clear career escalator and competency training to support individuals in more junior posts. Recruiting outside the hospital talent pool has been partially successful but the timely recruitment of these key positions leaves us at risk if we do not appoint first time. 2.2 In the hospital, the clinical services are grouped into directorates each having a clinical director; they work in collaboration with a divisional manager and a lead nurse. (see Appendix 1) With the exception of the medical division, each divisional manager has responsibility for more than one directorate. For some time concerns have been expressed regarding the size and structure of the divisions. Ad hoc changes have been implemented, but this is the first full review to take place for some time. Recent retirements and shifting managerial responsibilities created an opportunity to consider those issues against a background of the Trust s strategic directions and wider developments in cancer, urgent and emergency care. 3. KEY ISSUES 3.1 The Medical Directorate The Directorate has debated splitting more than once, driven by concerns regarding the size and complexity of the directorate delivering acute and speciality medicine. Its operational budget is large and delivers care across a wide range of services. Previously, proposals to divide the directorate have not been supported by the majority because of the integrated nature of the general and speciality services delivered. Recently, the managerial responsibility for endoscopy services was transferred from Critical Care to the Medical Division in recognition that the majority of the financial and operational issues sat there. The implementation of SLM enables some of the complex financial relationships to be sorted and the changing provision of medical staff in training has alleviated issues around junior doctors rotas and both of these changes create an opportunity for separation of some services. Oncology and haematology are functionally separate from the rest of the medical division and work closely together to deliver care and treatment to people with cancer. The waiting times in the sub-specialities are often a part of clinical pathways for surgical cancers and there is a demanding capital developments programme to deliver over the next two years. Board Date: 30 July 2008 2 of 5
The single Clinical Director within medicine has had a challenging role as they have needed to have a wide knowledge base to represent some very different specialities, for example, cancer and acute medicine. 3.2 Emergency and Urgent Care Urgent and emergency care has been reviewed at length within the hospital through the Acute Models of Care working group. The development of an emergency hub is the subject of an outline business case which will bring all adult emergency admissions to a location adjacent to ED before 2010. The co-location of ED and EMU is a top priority for the Trust to run services more efficiently and effectively. DPCT have an explicit agenda to reduce urgent and emergency admissions to hospital, they have a redesign project to locate GPs in both ED and EMU to reduce admissions and enable early discharges. The challenging delivery of the 2 hour maximum wait in ED will need a focussed and engaged response, it being potentially delivered in very different ways across the categories of attendances in ED. Patient s attendances with minor injuries and illness may require a different systemic approach to major attendances and admissions. The links between the ED and EMU are growing and collaborative, but are not being aligned within the current management structure. Medical outliers have been a significant issue for the Trust this winter and have not reduced over the past four months. The impact on the Emergency Department has been considerable as the ability to accept direct GP referrals on EMU has been compromised. Although other speciality services also cause breaches of this target, by far the biggest issue is avoiding the medical take and expediting the transfer of ED conversions to medical admissions. There is a need for a focussed clinical and managerial approach to be established in order to address these issues, bringing acute medicine together with the Emergency Department in a single management structure will ensure that efforts are aligned and agreed at divisional level. 3.3 Cancer Services and the Breast Care Unit The NHS Cancer Services Plan proposed a ten year plan to improve cancer treatment and survival in England. It has been supplemented by other standards and guidance with the publication of the Cancer Reform Strategy in December 2007: NICE Improving Outcomes Guidance (IOGs) Manual of Cancer Standards NICE guidance on recommended therapies, drugs, and surgical interventions Cancer Reform Strategy December 2007 The Cancer Services directorate has stood outside the clinical managerial structure since its inception; initially its responsibilities to lead changing attitudes and behaviours to the timely treatment and care of people with cancer. It has a small team of operational managers who are responsible for monitoring and reporting waiting times, acting as liaison, co-ordinators and trackers for treatment and care. The Breast Care Unit currently sits with the for Surgery. This is a legacy arrangement from the individual s previous role as the Cancer Services manager. As he is now moving post the future of the unit needs to be regularised. Board Date: 30 July 2008 3 of 5
4 PROPOSALS 4.1 The Emergency Department should move from Critical Care directorate to the Acute Medical directorate. 4.2 Oncology and haematology should become part of the Cancer Services directorate and transfer under the responsibility of the for C&WH 4.3 The Breast Care Unit should transfer to the Cancer Services Directorate to bring together responsibilities for Women s Services under one and align specifically cancer related services into a lead directorate. 4.4 The Critical Care directorate has been considerably reduced in size by these changes and it offers the opportunity to move Hospital Sterile Delivery Unit to a single managerial structure which will enable better communications between clinical services and support services led by a. 4.5 The role of clinical service manager is standardised in all divisions and rotational posts are designed to ensure that individuals are exposed to a wide range of clinical experiences with a strong competency framework to support them linked to external training. This will ensure there development of a talent pool for the future. 5 RECOMMENDATIONS 5.1 The Board is asked to note the changes that are planned and will be implemented during 2008/09. Board Date: 30 July 2008 4 of 5
CLINICAL DIRECTORATES APPENDIX 1 Acute and Specialist Medicine General and Specialist Surgery Orthopaedics and Critical Care Child and Women s Health and Cancer Services Professional and Diagnostic Services Clinical Director Clinical Director (General) Clinical Director (Orthopaedic) Clinical Director (CWH) Clinical Director (Professional) Directorate Manager Directorate Accountant Clinical Director (Specialist) Clinical Director (Critical Care) Directorate Manager Clinical Director (Cancer) Head of Midwifery (Cancer) Clinical Director (Diagnostic) Services (Acute) Drs in Training Elderly Care Emergency Department Emergency Medicine Endocrinology Stroke and Rehabilitation Services (General) Breast Surgery Colorectal Surgery General Surgery Thoracic Surgery Upper GI Surgery Urology Vascular Surgery Services (Or) Fracture Clinic Orthopaedic Outpatients Orthopaedic Surgery Rheumatology Trauma Surgery Services (CWH) Child Health Child Protection Fertility Services Gynaecology Obstetrics Oncology Midwifery Neonatology Paediatrics Services (Professional) Chaplains Chiropody Clinical Measurements Exeter Mobility Centre Medical Equipment Management Medical Physics Nutrition and Diabetes Occupational Therapy Osteoporosis Service Pharmacy Physiotherapy Services (Specialist Medicine) Cardiology Dermatology Gastroenterology Mardon House Medical Outpatients Neurology Neurophysiology Respiratory Medicine Renal Services Tissue Viability/Special Needs Services (Specialist Surgery) Ophthalmology Oral Surgery Orthodontics Orthoptics Otolaryngology Plastic & Reconstruction Surgery Services (Critical Care) Anaesthetics Day Care Unit *Hospital Sterile Delivery Unit ICU/HDU Pain Services Theatres Services (Cancer) *Breast Care Unit Haematology Oncology Trust wide co-ordination & development of cancer services NSF & NICE implementation National Cancer Plan & Cancer waiting times Services (Diagnotics) Pathology Blood Transfusion Clinical Chemistry Immunology Microbiology Molecular Genetics Mortuary Radiology/Medical Imaging CT Scanning MRI Medical photography Ultrasound *not yet transferred, Board Date: 30 July 2008 5 of 5