Bedfordshire and Milton Keynes Healthcare Review: A case for change EMBARGOED UNTIL 1500 HOURS WEDNESDAY 9 APRIL

Bedfordshire and Milton Keynes Healthcare Review: A case for change EMBARGOED UNTIL 1500 HOURS WEDNESDAY 9 APRIL

2 Bedfordshire and Milton Keynes Healthcare Review: A case for change Foreword As clinical leaders in Bedford Borough, Central Bedfordshire and Milton Keynes, we have been charged by our patients and the public to make sure the healthcare they receive helps them live the lives they want to lead. To meet our populations needs for healthcare, we must make sure they can use effective and safe healthcare services that consistently deliver good patient experiences. We are finding it is becoming increasingly difficult for us to be certain that healthcare services in Bedford Borough, Central Bedfordshire and Milton Keynes can continue to provide the quality of care we expect and our patients deserve, without support and reshaping. The challenges we face are described in this document. This case for improvement is our explanation of those challenges as they affect Bedford Borough, Central Bedfordshire and Milton Keynes. It is also our request to you to tell us what matters to you. In doing so, you will be helping us design a local healthcare system fit for the 21st Century. Dr Paul Hassan, Bedfordshire CCG Dr Nicola Smith, Milton Keynes CCG Dr Jane Halpin, NHS England

Bedfordshire and Milton Keynes Healthcare Review: A case for change 3 Contents Chapter Title Page number 1 Summary 4 2 Introduction 9 2.1 Who we are 9 2.2 Why we want to undertake this review 9 2.3 Aims and objectives of the review 10 2.4 The national context 11 3 How local healthcare is coping with patients needs today 13 3.1 How and where care is provided 13 3.1.1 GP surgeries 13 3.1.2 Community healthcare services 14 3.1.3 Hospital provision 16 3.1.4 The interface with transport services 19 3.1.5 The interface with mental healthcare 20 3.1.6 The interface with local authority provision 21 3.2 Quality of care provided to local people 22 3.2.1 Domain 1: Preventing people from dying prematurely 22 3.2.2 Domain 2: Enhancing quality of life for people with long-term conditions 23 3.2.3 Domain 3: Helping people to recover from episodes of ill health or following injury 24 3.2.4 Domain 4: Ensuring people have a positive experience of care 24 3.2.5 Domain 5: Treating and caring for people in a safe environment and protecting them 27 from avoidable harm 3.3 The resources available 29 3.3.1 Workforce 29 3.3.2 Finances 30 4 The challenges of tomorrow 32 4.1 Demographic change 32 4.1.1 Growth and age profile 32 4.1.2 Socioeconomic inequalities and lifestyle choices 33 4.2 Keeping up with advances in care delivery 33 4.2.1 Redesigning processes 33 4.2.2 Maintaining specialist expertise 34 4.2.3 Round the clock and consultant-led services 35 4.2.4 Using technology to full effect 35 4.3 The changing working habits of healthcare professionals 37 4.4 Paying for the care we want 37 5 The opportunities in Bedfordshire and Milton Keynes 39 5.1 Our ambition: patents at the heart of care 39 5.2 Prevention and early intervention 40 5.3 Learning from elsewhere 40 5.4 Using the Better Care Fund as a catalyst to join up care 42 5.5 Rewarding better outcomes for patients 42 5.6 Promoting this area as the place to work 43 6 Have your say 44 6.1 How to get involved 44 6.2 Questions to consider 45

4 Bedfordshire and Milton Keynes Healthcare Review: A case for change 1. Summary This document sets out the reasons why we the clinical leaders of NHS Bedfordshire Clinical Commissioning Group, NHS Milton Keynes Clinical Commissioning Group and NHS England (in our areas) believe a review of healthcare services is necessary and how we plan to undertake that review. Introduction Our three organisations are responsible for planning, designing and buying healthcare services that meet the needs of patients in Bedford Borough, Central Bedfordshire and Milton Keynes. The two clinical commissioning groups are clinicianled organisations and our aim is to have in place the best quality care possible for patients. To achieve this, we have a combined budget of around 680 million each year. Decisions on how those funds are spent are made through a standard commissioning process that starts by understanding the needs of a population and identifying gaps in the healthcare available to address those needs. In the past, such commissioning has been done for specific health conditions or for care in specific settings. This has resulted in local NHS services over time becoming complex organisations with often over-bureaucratic processes. These may not be right for delivering 21st Century care, not least because they may not take account of interdependencies between specialties or population groups. We know that not all local services are currently coping well with patient needs. Patients and the public have told the CCGs and NHS England (in our area) repeatedly that services are difficult to navigate, are often impersonal, and people fall through the cracks between different providers. Evidence shows that today s local healthcare services are fragmented, inequitable and inefficient and do not deliver the best possible outcomes for patients. If we do nothing, the situation will worsen: we will have old-fashioned models of care that do not attract staff to work here, services that become increasingly overstretched and unsafe, and growing financial pressures in each institution that cannot be addressed. This will all result in patient care suffering. Therefore, Bedfordshire CCG, Milton Keynes CCG and NHS England have decided to work together to review more of the local healthcare system at the same time. This collaboration in no way implies that, at the end of the review, the same solutions or recommendations will be applied to healthcare across Bedford Borough, Central Bedfordshire and Milton Keynes. Any commissioning decisions will be made independently by each CCG on behalf of its own local population. Given the scale of this review, the CCGs and NHS England are working with two national bodies: Monitor (the regulator of Foundation Trusts in England); and NHS Trust Development Authority (the regulator of non-foundation Trust hospitals in England). McKinsey & Company has been contracted to support the review with research and analysis on behalf of all the bodies and has significant experience of supporting similar largescale redesign projects both in the NHS and abroad. The review takes place against the backdrop of the review into care at Mid-Staffordshire NHS Foundation Trust, the subsequent review of 14 hospital trusts and foundation trusts with higher than expected mortality, and the expectation of delivery against the NHS Outcomes Framework. The findings of these reviews re-emphasise the national need for new ways to deliver NHS care that promote a caring and learning culture, with strong leadership and improving patient outcomes all within tight financial constraints. This will require change as much in general practice and community care as it does in hospitals, and the scale of transformation needed has been highlighted by the Royal Colleges and national politicians. The review aims to produce, by July 2014, a range of options for delivering affordable high quality healthcare now and into the future for the people of Bedford Borough, Central Bedfordshire and Milton Keynes.

Bedfordshire and Milton Keynes Healthcare Review: A case for change 5 From the outset, our purpose as commissioners has been clear. We aim to redesign services so that: People can be supported to take better care of themselves, lead a healthier lifestyle, understand where and when they can get treatment if they have a problem, understand different treatment options, and better manage their own conditions with the support of healthcare professionals if they wish. Older, frailer people are supported on a 24 hours a day, seven days a week basis to maintain their health, dignity and independence at home. When someone has an urgent healthcare need, they can easily access a primary care clinician 24 hours a day, seven days a week by telephone, email and face to face consultations in local, easily accessible facilities as close to home as possible. If they need to see a specialist or receive support from community or social care services, this will be organised in a timely way and GPs will be responsible for co-ordinating the delivery of their health care. If they need to be admitted to hospital, it will be only when they require acute specialist interventions that cannot be delivered in community settings, and then it will be to a properly maintained and up-to-date facility where they receive care delivered by highly trained specialists available seven days a week with the specific skills needed to treat them. To develop the options, the review will: Assess the current and future predicted needs of the populations of Bedford Borough, Central Bedfordshire and Milton Keynes. Seek out and listen to the opinions and feelings of local people about the priorities and preferences they have about their healthcare. Learn from examples of healthcare services in the UK and abroad that provide high quality care and good outcomes to their patients. Work with local clinicians to understand what works and doesn t work well with existing healthcare provision in Bedford Borough, Central Bedfordshire and Milton Keynes. It is highly unlikely that the status quo will be one of the options to emerge from the review. For all the reasons detailed in this report inequities in provision of care and in patient outcomes, the workforce shortages already faced by our providers, and the lack of effective integration between providers it is becoming increasingly difficult to assure the public that existing services are consistently safe and that they can continue to provide the best care possible. Changes to the status quo will have implications for general practice, community-based care and hospital-based care. But changes that mean our local healthcare system can consistently deliver better outcomes for more people more often and more efficiently must be worthwhile. Identifying the right changes is what this review is for. How local healthcare services are coping with patients needs today The NHS operates as a dispersed network of services across Bedford Borough, Central Bedfordshire and Milton Keynes, which provides care directly within people s homes, out of GP surgeries and community clinics in most of the larger towns and settlements, and from a number of public and private hospital sites in and around the area. (Although not directly covered in this review, mental healthcare and social care are inextricably linked with the three types of service that are.) While care provided by this network is usually good, there are signs of strain and evidence on local care quality shows the services are not always as effective and joined up as they could be. In addition, local NHS services are facing the kind of workforce shortages and financial constraints that are challenging NHS organisations in many other areas of the country. Current issues in local services While most GPs, community clinics and hospitals are meeting most basic standards of safety and there are local examples of best practice, the care they provide is inconsistent and not always of the quality expected by the public.

6 Bedfordshire and Milton Keynes Healthcare Review: A case for change The general practice offer to patients in Bedfordshire and Milton Keynes varies significantly, depending on where they live, the size and configuration of the practice with which they choose to register, and the nature of that locality s out of hours provider. There are noticeable gaps in the services available from community service teams with, for example, insufficient sub-acute care in Bedford Borough. There are also risks of duplicating community services with services provided as outreach care by hospitals, such as Hospital at Home. In hospital care, almost all local hospitals have struggled to meet NHS Constitution waiting time targets consistently in key areas such as A&E and orthopaedic inpatient care. In addition, the two acute NHS hospitals in Bedford Borough and Milton Keynes and some units at other hospitals are relatively small scale, and their size has an impact on the services they can provide. For instance, the maternity units at Bedford Hospital, Milton Keynes Hospital, Kettering Hospital and Hinchingbrooke Hospital are all classified as small. This means they are only required to have a minimum 60 hours consultant obstetrician presence on labour ward and are limited to taking relatively low risk deliveries (over 32 weeks gestation). In addition, the care patients receive at hospital can differ significantly, depending on whether they are admitted to hospital at a weekend or on a weekday. Quality of care in the five main outcome domains An assessment of the quality of local care against the five main domains identified in the NHS Outcomes Framework suggests that, overall, our healthcare systems are not providing consistently joined up and effective care. People can find it difficult to make appointments with their GP when they want to (especially in Milton Keynes), and may either not seek help missing an opportunity for healthcare to intervene early or choose to use hospital-based emergency care instead. With delays in diagnosis of long term conditions and without adequate support to live with a long term condition, again, opportunities for early intervention when healthcare can be most effective are missed. The often unpredictable peaks in emergency activity overstretch hospital resources, with knock-on impacts on planned care, and create unnecessary patient safety risks at times of extreme pressure, times which are becoming increasingly common. Discharges home can be poorly co-ordinated between the hospital, general practice and community services, running the risk of deterioration in the patient s health and readmission to hospital. Although quality issues like these are seen across all local health systems, the evidence suggests particular strain in general practice in Milton Keynes, and in especially Bedford Hospital, Milton Keynes Hospital, Northampton General and Buckinghamshire Healthcare. Workforce and financial challenges Our health services are also challenged by the workforce shortages that affect the whole country. Local hospitals particular workforce shortages include middle grade A&E doctors, health visitors, experienced nursing staff, neonatal nurses, sonographers and Operating Department Practitioners (ODPs). With significant proportions of clinical staff nearing retirement age, there is a major risk that vacancy rates will increase. And like many other areas of the NHS, the current financial position locally is already stretched. The Bedfordshire health economy will end the 2013/14 financial year in deficit by around 9 million and Milton Keynes health economy by around 12 million, compared to a total budget of 680 million. This position puts at risk the ability of both health economies to invest in sufficient new technology or staff numbers to continue to deliver safe care into the future. Tomorrow s challenges Keeping up with expected demographic changes, advances in care delivery, advances in technology and financial pressures will collectively make healthcare services more difficult to provide in their current form in future. Together, the strains in today s services and the challenges of tomorrow add up to an imperative need to update and reform the pattern of healthcare provision in Bedfordshire and Milton Keynes. Existing services can neither absorb the additional population requirements nor afford to

Bedfordshire and Milton Keynes Healthcare Review: A case for change 7 implement the models of care that deliver the best quality of care and outcomes for patients. (a) Demographic change By 2021 (only seven years from now), local populations are expected to grow by an additional 45,000 people in Bedfordshire and 39,000 in Milton Keynes, all of whom will require access to at least general practice and urgent care. In addition, an estimated 50,000 will develop long term conditions and need support and care to live well with their condition. As elsewhere in England, modern lifestyles are creating additional health problems, worse in more socioeconomically deprived areas. Obesity, smoking and alcohol misuse all place additional requirements on the NHS into the future. (b) Advances in care delivery Recent experience shows that local services have not always kept up with improvements in healthcare, and so patients are not guaranteed always to receive the best possible care available. For example, some local services have been prioritised for redesign because of a crisis in their quality of care. However, the response to those incidents has taken a relatively narrow approach to the subsequent redesign, looking primarily at hospital-based services and only at a discrete service area (e.g. paediatrics). This misses the opportunity to improve quality and efficiency of care across complete pathways of care in community and hospital settings, which is currently best practice. Where planned or emergency hospital care is required, the best healthcare systems provide access to highly trained clinicians who are exposed to the numbers and range of patients required to develop and maintain their skills. In order for specialists to maintain their skills, specialist services are increasingly being concentrated in specific locations, allowing clinicians to see a sufficiently high number of patients, effectively utilise expensive equipment and to work collaboratively with other relevant professionals. Every Royal College has recommended for its specialty that this approach of centralisation is one of the key ways of improving care and outcomes for patients. This is a recommendation we need to follow in our area. Quality of care and health outcomes also improve when senior doctors and their teams are available seven days a week, 24 hours a day to make early diagnoses and decisions and this is now NHS England policy. However, it is financially and clinically impossible to provide consultant-delivered care safely seven days a week using the models of care that currently exist in most of our local providers. Finding a way to do this means redesigning those models. Advances in technology also offer an important opportunity for making clinical and financial improvements at the same time. The potential for technology to change how people interact with the NHS is huge, especially by allowing healthcare professionals to communicate better across teams and networks. Technology can increase access for patients to experts that they would not usually be able to see, and with very little inconvenience and expense to themselves or the NHS. Within the NHS, there are pockets of exciting innovation in the use of technology in medicine, and implementation of technology is being supported and encouraged by NHS England. So far, within Bedfordshire and Milton Keynes despite being the home of innovative industries such as the Open University, Amazon and Red Bull Racing technological innovation has not systematically been incorporated into everyday practice in the local NHS. However, the introduction of any new technology comes with consequences. It requires investment, training and redeployment of resources to deal with, not least, the 24/7 nature of social media and technology. It also requires recognition of and planning for marked changes to traditional patterns of delivery, such as falling numbers of hospital-based outpatient clinics as more such consultations are done on-line. (c) Changing workforce habits With the introduction of working time directives and cultural changes in work/life balance, the healthcare workforce behaves differently to

8 Bedfordshire and Milton Keynes Healthcare Review: A case for change the way it did only a few decades ago. GPs are increasingly choosing salaried positions rather than partnerships, and newly qualified consultants are less experienced than their predecessors. Our plans for the future must take these changes into account. (d) Paying for the care we want Even if healthcare commissioners and providers in Milton Keynes and Bedfordshire delivered some of the most stringent cost-cutting programmes in the country over the next five years, the two health economies would struggle to break even. If nothing changes to address the underlying factors driving these financial pressures, then by 2018/19, the two local CCGs could have to save between 50 million and 70 million between them just to break even. In addition, the two local acute hospitals face a projected 47 million deficit over the same period. The opportunities The people leading our local health systems share an ambition to put patients at the heart of care, to support them living independent lives at home for as long as possible, and to do so in the most costeffective way possible. The opportunities for achieving this ambition that we have so far identified are to: Push hard on prevention of ill-health, patient support and empowerment, and early intervention if ill-health does arise. Use the Better Care Fund as a catalyst to join up care, recognising that the fund is constituted from resources saved by reducing emergency admissions to hospitals, requiring both community and hospital services to be significantly redesigned. Reward providers for delivering better outcomes for patients, thereby incentivising collaboration rather than competition between providers. Promote Bedford Borough, Central Bedfordshire and Milton Keynes as the places to come and work, building on the efforts to attract business to the local area. Have your say Any and all comments, suggestions and thoughts on our local healthcare services are welcomed in order to inform the decisions of the CCGs and NHS England, and people can participate through our events, website and social media. In particular, we welcome thoughts on the questions set out at the end of this report, including: Does this case for change reflect your perception of healthcare in Bedfordshire and Milton Keynes today? Do you think we have been realistic about the challenges local healthcare services face tomorrow? Overall, on what would you most like us to invest in the coming years? Equally, where would you like us to try hardest to make savings? Learn from innovation in clinical organisation and processes elsewhere that seem to be demonstrably improving outcomes for patients (e.g. Cornwall and Isles of Scilly pioneer project.

Bedfordshire and Milton Keynes Healthcare Review: A case for change 9 2. Introduction 2.1 Who we are Clinical commissioning groups (CCGs) were established across the NHS in England in 2013 to buy healthcare services for the patients living in their area. Each CCG is made up of doctors, nurses and other professionals who use their knowledge of local health needs to plan, design and buy services for their local community from any service provider that meets NHS standards and costs. This means care for patients is designed with knowledge of local services and commissioned in response to their needs, and is therefore a better service for local people. NHS Bedfordshire CCG serves the local authority areas of Bedford Borough (159,200 people) and Central Bedfordshire (255,200 people). NHS Milton Keynes CCG serves the 252,400 residents of Milton Keynes Council. Both CCGs are accountable for their decisions through NHS England to the Secretary of State for Health. NHS England buys all general practice care across the country. Its Hertfordshire and South Midlands Area Team undertakes this for Bedfordshire and Milton Keynes, and works closely with the two CCGs to make sure all the care received by our local residents whether in general practice, in a community clinic, at hospital or at home provides a good patient experience, is safe and effective. To plan and buy the right type and quantity of healthcare, CCGs and NHS England use a standard commissioning process. This is a cycle of work that starts by understanding the needs of a population (using Joint Strategic Needs Assessments) and identifying gaps or weaknesses in current provision, then describing and buying services to meet those needs. Throughout the commissioning cycle, the views and feedback are sought of people who use or might use services to make sure the right services are bought, the right outcomes are being measured, and providers are delivering the quality of care that they are contracted to provide. Healthwatch, operating in Bedford Borough, Central Bedfordshire and Milton Keynes, gives patients and communities a voice in commissioning decisions and hold the CCGs to account for our engagement with patients and the public. 2.2 Why we want to undertake this review In the past, planning and redesign has been undertaken for specific health conditions (such as a new asthma service, for example) or care to be provided in specific settings (such as a community nursing service). Local NHS services have therefore been built up incrementally over decades, evolving gradually to deal with changing health needs, clinical standards and public expectations. This evolution has produced some complex organisations and networks of facilities that may not be right for delivering the care patients need today or may need in the future. In other words, if we were starting with a blank sheet of paper, we might design our services differently to suit better the health needs of today s and tomorrow s patients. Traditionally, we would review care by looking at one population group or service at a time. However, that approach would take years, longer than the current system can afford to wait. Furthermore, that piecemeal approach doesn t take into account some of the interdependencies between providers and services which, without considering in the round, could lead to unintended negative consequences (in terms of workforce, safety or finances) on other parts of healthcare. Although serving very different populations, Bedfordshire and Milton Keynes CCGs find themselves with similar problems: significant concerns about the ability of the healthcare systems in both areas to continue to deliver safe care, given the challenges they face now and into the future (and which are described in this document). Given the scale of these challenges and the dangers of reviewing services one at a time, the two CCGs, along with NHS England, agreed that we can best describe future healthcare services for the people of Bedford Borough, Central Bedfordshire and Milton Keynes if we look at and review more of the healthcare system all at once.

10 Bedfordshire and Milton Keynes Healthcare Review: A case for change 2.3 Aims and objectives of the review This review aims to produce, by July 2014, a range of options for delivering affordable high quality healthcare now and into the future for the people of Bedford Borough, Central Bedfordshire and Milton Keynes. Those options can then be taken through a formal consultation process with the public and stakeholders to inform the CCGs and NHS England s final decisions on the best services to buy for our patients within available resources. From the outset, our purpose as commissioners is clear. Our aim is to redesign services, so that: People can be supported to take better care of themselves, lead a healthier lifestyle, understand where and when they can get treatment if they have a problem, understand different treatment options, and better manage their own conditions with the support of healthcare professionals if they wish. Older, frailer people are supported on a 24 hours a day, seven days a week basis to maintain their health, dignity and independence at home. When someone has an urgent healthcare need, they can easily access a primary care clinician 24 hours a day, seven days a week by telephone, email and face to face consultations in local, easily accessible facilities as close to home as possible. If they need to see a specialist or receive support from community or social care services, this will be organised in a timely way and GPs will be responsible for co-ordinating the delivery of their health care. If they need to be admitted to hospital, it will be only when they require acute specialist interventions that cannot be delivered in community settings, and then it will be to a properly maintained and up-to-date facility where they receive care delivered by highly trained specialists available seven days a week with the specific skills needed to treat them. By together undertaking the analysis and assessments of the scale of the problems and learning from elsewhere, the CCGs can make best use of their resources. This collaboration in no way implies that, at the end of the review, the same solutions or recommendations will be applied to healthcare across Bedford Borough, Central Bedfordshire and Milton Keynes. Any subsequent consultations will be run separately in each CCG area and any commissioning decisions made independently by each CCG on behalf of its own local population. Because of the scale of this review, the CCGs and NHS England are working with two national bodies: Monitor (the regulator of Foundation Trusts in England); and NHS Trust Development Authority (the regulator of non-foundation Trust hospitals in England). McKinsey & Company has been contracted to support the review with research and analysis on behalf of all the bodies and has significant experience of supporting similar largescale redesign projects both in the NHS and abroad. Although on a bigger scale to other reviews and redesigns that the CCGs have done, the usual commissioning processes will apply to this review, not least the involvement of patients and the public in describing what works and doesn t work so well. To develop the options, the review will: Assess the current and future predicted needs of the populations of Bedford Borough, Central Bedfordshire and Milton Keynes. Seek out and listen to the opinions and feelings of local people about the priorities and preferences they have about their healthcare. Learn from examples of healthcare services in the UK and abroad that provide high quality care and good outcomes to their patients. Work with local clinicians to understand what works and doesn t work well with existing healthcare provision in Bedford Borough, Central Bedfordshire and Milton Keynes. The review covers healthcare for adults and children, from maternity and childbirth through to frailty and end of life. It includes both care that is planned (with booked appointments) and emergency care,

Bedfordshire and Milton Keynes Healthcare Review: A case for change 11 care during pregnancy, and care provided in general practice, in patients homes, community settings and in hospitals. While it touches on aspects of mental healthcare that link most closely with physical healthcare (such as psychological support for people with long term conditions), it will not cover specialist mental healthcare. In Bedford Borough and Central Bedfordshire, mental healthcare and child and adolescent mental health services are being procured during 2014 in a process running in parallel with but separate from this review. In Milton Keynes, retendering was undertaken in 2012/13, with services now provided under a three year contract to April 2016. Social care will not be studied in detail in this review, but referenced where it is felt to have an important part to play with healthcare in improving outcomes for patients, such as through the development of integrated care underpinned by Better Care Funds in each local authority area. The review will cover only NHS-funded healthcare, and not privately funded or insured healthcare provision. It will uphold the rights and pledges set out in the NHS Constitution for staff, patients and the public from the local and national NHS. 2.4 The national context The NHS still reverberates to the findings of the review into care at Mid-Staffordshire NHS Foundation Trust, published by Robert Francis QC in February 2013 1. Every part of the NHS system providers, commissioners and regulators has a role in making sure patients receive safe high quality care. Francis s recommendations included the re-establishment across healthcare of a culture of patients first promoted by strong local leadership and transparent use of information to demonstrate that expected standards of care are being provided to patients. Sir Bruce Keogh s subsequent review of 14 hospital trusts and foundation trusts with higher than expected mortality rates echoed the need for strong clinical leadership and a culture of continuous learning and seeking to improve patient experience and outcomes. 2 To achieve these improvements requires close collaboration between hospitals and the health and social care services around them. As well as create CCGs, NHS England, Healthwatch and other entities, the reforms to the NHS set out in Health & Social Care Act 2012 described a new national focus on understanding, measuring and acting on patients perceptions of the impact on their quality of life of the care they receive. The mandate agreed between the NHS in England and the Secretary of State is based on the delivery by the former of agreed improvements in patient outcomes, with the expectation that patients will be involved in any and all decisions about their care and that NHS budgets will not be exceeded. This re-emphasis across the NHS on promoting a caring and learning culture, with strong leadership and improving patient outcomes within a limited national budget for healthcare means the way healthcare is delivered is being examined at all levels. For example, NHS England is leading a review of urgent and emergency care. 3 Its early conclusions are that safe urgent care for patients should not, in many instances, mean hospital-based care. Furthermore, in emergency situations such as heart attack and stroke, the safest and most effective care can be provided by consolidating specialist care in centres where there are the skills and experience to maximise the chances of survival and good quality of life for each patient. This is significantly different from the models of urgent and emergency care in most parts of the NHS in England today. Putting in place this safer and better model of urgent and emergency care has a number of wider implications: it will require change as much in general practice and community care as it does in hospitals. It will also influence how other aspects of healthcare for people with long term conditions such as diabetes, asthma and heart disease, for example are configured, to emphasise early 1 Available at: http://www.midstaffspublicinquiry.com/report (Last accessed March 19 2014) 2 Available at: http://www.nhs.uk/nhsengland/bruce-keogh-review/documents/outcomes/keogh-review-final-report.pdf (Last accessed March 19 2014) 3 Available at: http://www.nhs.uk/nhsengland/keogh-review/pages/published-reports.aspx (Last accessed March 19 2014)

12 Bedfordshire and Milton Keynes Healthcare Review: A case for change intervention and the prevention of the need for urgent or emergency care as far as possible. And it will require the seven day a week NHS as promoted by NHS England and the Academy of Royal Colleges 4 to become reality. The combination of responding to the Francis Inquiry s recommendations, delivering the NHS Outcomes Framework, and implementing national recommendations on improved models of care means inevitable change in how healthcare is delivered. However, the NHS is also facing significant financial challenges. Although it has been relatively protected from financial cuts during the government s public sector austerity programme, the NHS s year on year increases in funding fall well short of the 4-6% year on year growth in costs, and it has been estimated that, unless the NHS changes the way healthcare is delivered, there will be a funding gap of 30 billion a year by 2021. 5 In addition, local authorities social care budgets have been cut by over 2.5 billion since 2011 6 and increasing amounts of NHS funds are being transferred to councils to support social care. 7 In all, this is one of the worst financial periods the NHS has seen for the last 50 years, and it means the pace and scale of the required transformation in healthcare delivery is substantial. Politicians from all parties recognise the pressures on the National Health Service and the need from both quality and efficiency perspectives to move away from reactive hospital-based care towards early intervention and care based in general practice and community settings. 8 The proposed national policy levers differ between parties, but common themes are the necessity for closer collaboration between providers and strong local leadership, and recognition that no part of the health service neither hospitals, general practice nor community care is immune from these changes. 4 http://www.england.nhs.uk/ourwork/qual-clin-lead/7-day-week/7ds/ (Last accessed 26 March 2014) 5 Roberts A, Marshall L, Charlesworth A. A decade of austerity? Nuffield Trust,Deember 2012. http://www.nuffieldtrust.org.uk/sites/files/nuffield/121203_a_ decade_of_austerity_full_report.pdf (Last accessed 26 March 2014) 6 ADASS Budget Survey 2013 http://www.adass.org.uk/index.php?option=com_content&id=914&itemid=489 (Last accessed 26 March 2014) 7 http://www.england.nhs.uk/wp-content/uploads/2013/07/funding-transfer-to-sc-letter.pdf (Last accessed 26 March 2014) 8 The view from Westminster. Parliamentarians on the future of health and social care. Nuffield Trust, 2013

Bedfordshire and Milton Keynes Healthcare Review: A case for change 13 3. How local healthcare is coping with patients needs today The NHS operates as a dispersed network of services across Bedford Borough, Central Bedfordshire and Milton Keynes. This network provides care directly within people s homes, out of GP surgeries and community clinics in most of the larger towns and settlements, and from a number of public and private hospital sites in and around the area. NHS-funded providers of care work in partnership with each other and with social care to deliver good care to local patients. Health and social care should work as a joined up system providing the right care in the right place at the right time for each patient who needs it and in a way that gives them a good experience of their care. However, the evidence presented in this section shows that the care delivered to the people of Bedford Borough, Central Bedfordshire and Milton Keynes is inconsistent and not always of the quality expected by the public. While most providers are meeting most basic standards of safety and there are local examples of best practice, there are also local examples of care that lags behind best practice elsewhere in general practice, community services and hospital care. Patients outcomes are suffering because local providers are not collaborating effectively together as much as they can and should. As elsewhere in the country, local services also face staff shortages in critical areas, such as nursing and A&E, and increasing financial pressures. 3.1. How and where care is provided Below we describe the nature of existing local NHS provision and current signs of strain. 3.1.1. GP surgeries There is strong evidence that high-quality, wellled general practice results in better and more cost-effective patient care 9.The central function of the GP in the NHS is to provide comprehensive, compassionate medical care within the community, to an identified population of patients with whom the general practice team has a continuing relationship and responsibility. The wide mix of health problems seen and managed (everything from babies to older people and from mental illness to sports medicine) is one of the major attractions to doctors to work in this specialty. It requires significant collaboration with other health and social care professionals, in order to address the physical, social and psychological aspects of local patients wellbeing, in the context of their individual needs, their families and their communities. Because almost every member of the public is registered with a general practice, it is the part of the NHS with the greatest opportunity to proactively identify risk of ill health in the population to prevent illness and not just treat it. Most GPs are independent contractors to the NHS, providing healthcare through their practices under a standard national contract with NHS England. This independence means that in most cases, they are responsible for providing premises from which to practise and for employing their own staff. As well as core general practice, a practice may provide ancillary services such as phlebotomy (taking blood samples), medication dispensing, and may host specialist clinics on its premises. Within Milton Keynes, there are 165 GPs working from 28 practices on 28 sites. In Bedford Borough, there are 106 GPs working from 26 general practices, with 154 GPs and 29 general practices in Central Bedfordshire. (See Figure 1) Practices vary significantly in size, from single-handed doctor practices to practices with a dozen doctors working from that site. The number of people registered per whole time equivalent GP also varies widely from practice to practice, ranging from 1,077 to 2,964 in Bedfordshire and 931 to 3,424 in Milton Keynes. There is no optimal list size: while smaller practices often have the advantage of continuity of care, larger practices can offer a wider range of facilities for their patients. The sessional nature of general practice work means it is one of the specialties most suited to part time and flexible working. It also allows individual doctors to develop special interests in specific clinical 9 The 2022 GP. A vision for general practice in the future NHS. RCGP, London. May 2013

14 Bedfordshire and Milton Keynes Healthcare Review: A case for change areas (such as diabetes, cardiovascular disease or musculoskeletal care), in education of those training to be general practitioners (course organisers and tutors) or in local issues (for example on Local Medical Committees or clinical commissioning groups). Outside standard opening times, general practice is available through locality-based out of hours services: MK Urgent Care Services (covering Milton Keynes and some of west Bedfordshire, based on the Milton Keynes Hospital campus); Bedoc (covering Bedford, based on the Bedford Hospital campus); MDoc (covering Ivel Valley, based on the Biggleswade Community Hospital campus); and Care UK (covering West Mid Bedfordshire, Leighton Buzzard and Chiltern Vale, based on a number of sites across those areas). Patients can also receive general practice advice at the walk-in centres in Bedford and Milton Keynes, which have longer opening hours than standard general practices, and 24 hours a day via the 111 telephone service. The general practice offer to patients in Bedfordshire and Milton Keynes can vary significantly, depending on where they live, the size and configuration of the practice with which they choose to register, and the nature of that locality s out of hours provider. For example, in some parts of Bedfordshire and Milton Keynes, GP practices are conducting routine blood tests and coagulation monitoring for their patients, while in other practices patients are required to go to hospital for these routine services. It is possible for two similar patients registered with different practices to have their care managed in completely different ways: one may be seen by a GP with enough specialist knowledge of their condition to advise and treat without onward referral to a specialist, and all blood tests taken and medication dispensed without the patient needing to travel any further than that practice. On the other hand, with a similar condition, a patient at a different practice seen by a GP who does not have sufficient specialist knowledge in a practice without additional services may find they have to go to a hospital for everything from blood tests to specialist review. As well as being inequitable and often inconvenient for patients, this is also an inefficient way of delivering primary care. 3.1.2. Community healthcare services Community healthcare services cover a broad range of care: from wound care to podiatric surgery, speech and language therapy to continence services. Care is delivered from facilities with low numbers of beds, at community clinic sites and in patients own homes. By treating people at home and community and keeping people as independent as possible, the services prevent unnecessary admissions to hospital and can facilitate earlier hospital discharges. Community healthcare tends to be provided by specialist community healthcare trusts, some of which as in Bedfordshire and Milton Keynes also provide mental healthcare. To deliver the best possible patient outcomes, such organisations must work closely with general practice (to identify and care for patients at high risk of healthcare need), hospitals (to facilitate earlier discharge by providing care closer to home), and social care (to provide rehabilitation and reablement services). Community nursing, therapy and other communitybased services are provided in Bedford Borough and Central Bedfordshire by South Essex Partnership Trust (SEPT), and in Milton Keynes by Central North West London Trust (CNWL). In both areas, there have been successful collaborations with other parts of local health and social care services in projects such as the establishment of a sub-acute pathway of care in southern Bedfordshire (which helps older people regain their independence more quickly after a hospital admission) and an integrated health and social care adult community team in Milton Keynes. But both organisations rely on either GPs or hospital teams referring patients to community healthcare services, meaning patients must require medical help before they then receive community healthcare. The structure of community services, which has evolved over a number of years, is a range of different condition-orientated teams, such as Rapid Intervention Teams, Tissue Viability Teams, Continence Teams, and Rehabilitation and Enablement Teams. While the care provided by these teams is usually of high quality, there are noticeable gaps in the services available with, for example, insufficient sub-acute care in Bedford Borough, and unclear pathways for hospital patients who need to be non-weight bearing but who no longer need acute hospital care.

Bedfordshire and Milton Keynes Healthcare Review: A case for change 15 There is little formal collaboration beyond discrete projects with general practice and hospitals to improve and integrate the provision of care across institutional boundaries. Indeed, there is a risk that some services (such as Hospital at Home care and some paediatric outreach services) are being duplicated by community healthcare and local hospitals. All three local authority areas have developed community and neighbourhood voluntary groups, such as the good neighbour Village Care Schemes in Central Bedfordshire. There are also buoyant third sector and charity-based services operational in the three areas. Such schemes and providers have the potential to play a much greater part in a redesigned health and social care system that supports people at and close to their homes. Figure 1: Map of GP practices and community facilities Northamptonshire Bedford Borough Bedford Hospital NHS Trust London Road Queens Park Cambridgeshire Sandy Hospital GP practices Hinchingbrooke Hospital Cambridge University Hospital Chiltern Vale Bedford Ivel Valley Leighton Buzzard West Mid Beds Milton Keynes Biggleswade Milton Keynes Hospital Ampthill Flitwick Central Bedfordshire East & North Hertfordshire NHS Trust Leighton Buzzard Buckinghamshire Priory Gardens Luton & Dunstable Hospital Hertfordshire Buckinghamshire Hospital

16 Bedfordshire and Milton Keynes Healthcare Review: A case for change 3.1.3. Hospital provision Hospitals broadly provide three types of healthcare that require specialist skills and knowledge not available in general practice or in the community: Emergency care (accident and emergency (A&E) departments, and emergency admissions to hospital). Planned care (outpatients, diagnostic tests, and surgical procedures). Maternity (including obstetric) care. The three areas are, of course, interdependent, and all rely on internal support services such as radiology and pathology and external communitybased services. The smooth functioning of a hospital depends very much on both getting the balance right in the use of internal resources and the success of external collaboration. The more care can be planned in advance, the better the outcomes and experience for both patients and staff. In Bedford Borough and Milton Keynes, there are two acute NHS hospitals: Bedford Hospital and Milton Keynes Hospital Foundation Trust. (There is no acute NHS hospital facility within the Central Bedfordshire area.) Many residents of Milton Keynes and Bedfordshire also use hospital services in neighbouring areas. In particular, Central Bedfordshire residents travel to and use acute services at seven different hospitals, especially Luton & Dunstable Hospital Foundation Trust, but also Stoke Mandeville Hospital (part of Buckinghamshire Healthcare NHS Trust), the Lister Hospital (part of East & North Hertfordshire NHS Trust), Hinchingbrooke Hospital NHS Trust, and Addenbrookes Hospital (part of Cambridge University Hospitals NHS Trust). Milton Keynes residents also travel to Stoke Mandeville Hospital and Northampton General Hospital NHS Trust. NHS-funded planned procedures (such as joint replacement surgery) are also increasingly being undertaken at private facilities in Bedfordshire and Milton Keynes, in line with the national picture. (In 2011/12, across England almost one-fifth of hip or knee replacements were undertaken in private facilities. 10 ) (See Figure 2) Each year, a small number of people requiring certain specialist services (e.g. complex cancer care) travel to centres in Oxford and Cambridge as well as London. In terms of numbers of beds available, both Bedford Hospital and Milton Keynes Hospital are amongst the smallest NHS hospitals in the area (see Table 3.1). Table 3.1: Average daily numbers of available and occupied beds (October-December 2013) 11 Hospital Available general and acute overnight beds % occupancy of general and acute overnight beds Available daycase beds Hinchingbrooke Healthcare NHS Trust 191 87% 38 Bedford Hospital NHS Trust 328 91% 42 Milton Keynes Hospital Foundation Trust 404 97% 62 Kettering General Hospital Foundation Trust 524 95% 38 Luton & Dunstable Hospital Foundation Trust 548 85% 45 East & North Hertfordshire NHS Trust 678 86% 54 Buckinghamshire Healthcare NHS Trust 682 91% 21 Northampton General NHS Trust 741 88% 81 Cambridge University Hospitals Foundation Trust 939 89% 236 10 Public payment and private provision. May 2013 http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/130522_public-payment-and-privateprovision.pdf (Last accessed 26 March 2014) 11 Sources: KH03 quarterly return, NHS England (http://www.england.nhs.uk/statistics/statistical-work-areas/bed-availability-and-occupancy/ )