service redesign case study March 2013 No. 3 Reconfiguring acute services Key points Reach a shared understanding of the case for change across the local health economy. Start public engagement as early as possible. Encourage clinicians to make the case for change. Hold regular face-to-face discussions with politicians and local stakeholders. Listen to all interest groups and accommodate their views where possible. Discussions about one aspect of care can provide a userful forum for a wider debate about the shape of services. In common with elsewhere in the UK, the health economy in Buckinghamshire is under pressure from demographic changes: people are living longer but not necessarily healthier lives, with more long-term conditions that require ongoing management. With some emergency and general medical services split over two sites, hospitals in Buckinghamshire were placed under additional pressure. The Better Healthcare in Bucks programme sought to reshape services in the region to deliver better, more cost-effective and sustainable care in the most appropriate setting. The case for change in Buckinghamshire Buckinghamshire is currently served by two main hospitals, at Stoke Mandeville and Wycombe. In 2005, trauma and emergency surgical services were centralised at Stoke Mandeville hospital with Wycombe retaining planned surgery, an Emergency Medical Centre, and specialist cardiac and stroke services. This was followed, in 2009, by Wycombe hospital transferring its paediatric inpatient activity, neonatal care and obstetric-led maternity services to Stoke Mandeville. As a result, both Stoke Mandeville and Wycombe hospitals were running 24/7 emergency services (although trauma was centralised) and general medical acute care, dividing consultants and other senior teams over two sites. Research suggests that, for patients, greater continuity of consultant time can lead to shorter length of stay and reduced mortality rates. Buckinghamshire Healthcare NHS Trust (BHT) was also struggling to recruit sufficient numbers of specialist staff such as A&E consultants to safely maintain services across the two sites.
The question was How do we start these conversations with the public around what the changes might mean? This took place against a backdrop of a national trend of increasing emergency admissions and the higher costs associated with this. 1 These factors created a strong case for greater centralisation of inpatient care. This would enable Buckinghamshire s hospitals to establish centres of excellence for specialties such as gastroenterology, respiratory diseases, diabetes and older people s services. The vision was of a consultant team around the patient, concentrated on one site. After the local primary care trust (PCT) divested itself of community services, BHT had become an integrated trust. This paved the way for the development of a care model that was also based closer to home, for example, in outpatient services and community nursing and therapy teams. The earlier Care for the Future programme, led by PCTs in Buckinghamshire and Berkshire, looked at how local health services could best be provided from 2013 onwards. 2 The review recommended that the remaining emergency services would benefit from being centralised. This resonated with an emerging clinical and managerial consensus at BHT that centralisation of services would lead to improvements in the quality of care. Fact file Name of change programme: Partners: Buckinghamshire and Oxfordshire PCT Cluster, and Buckinghamshire Healthcare NHS Trust Approx. population served: 500,000 Type of programme: acute service reconfiguration Current stage: Consultation programme completed. Nearing the completion of implementation phase. Continuing ongoing dialogue with stakeholders. Designing the Better Healthcare programme The starting point for Better Healthcare in Bucks (BHiB) was a patient and public engagement programme exploring two themes: providing care closer to home for the majority of patients establishing centres of excellence for those patients admitted to hospital. This was followed by further discussion with clinicians, enabling them to refine their vision and provide more detailed proposals. A three-month public consultation took place in 2012, which followed the Department of Health s Consultation Gateway process guidelines. These discussions showed support for a model of care delivered closer to home and an understanding that consolidation of acute specialties might increase travel times for those admitted to hospital. Engaging with clinicians Throughout the process, clinical engagement was seen as vital. Alongside the engagement and public consultation processes, discussions took place with GPs from the two local clinical commissioning groups about how they could work with hospitalbased clinicians. At a series of clinical summits, the rationale for change was discussed, along with ideas for implementing service change. The clinician-to-clinician workshops influenced the shape of the proposed new care models. Modifications included plans for a multi-disciplinary day assessment unit to which GPs could refer patients for diagnosis and treatment; an improved system of direct access for GPs to telephone advice from consultants; and a step-down ward at Wycombe hospital. 02
The redesign aimed to create safe and sustainable services for the future NHS Confederation These measures were designed to reduce cautionary referrals and emergency admissions, and to reduce the distance that patients and their families needed to travel from home. The vision was of a care pathway managed throughout by the same expert teams. Addressing patients concerns A recurrent theme for patients and the public was transport. Parts of Buckinghamshire are poorly served by public transport and this added to natural concerns about getting to and moving between sites; parking was also cited as an issue. In response to this, a transport group was established made up of council, hospital and ambulance service representatives, which looked at the issues in more depth and even held its own engagement sessions. Outcomes from this group were improved and free travel on local bus networks, and the establishment of a countywide community transport hub to provide a central information point for community and voluntary transport. Many were also confused about the nature of the plans, including where they would have to go for treatment of a particular condition. Addressing these concerns became a core element of the engagement process that followed. In January 2012, the programme team began a three-month public consultation, building on the relationships established the previous year. A number of clinically-led meetings, often attended by medical directors from both BHT and the PCT, were held to explain the proposed changes. The most significant challenges came at public meetings in Wycombe, where fears were expressed that the reduction in services would lead to closure of the local hospital. In response to this the team emphasised that the stroke and cardiac unit based at Wycombe were leaders in their field and achieving very good patient outcomes, and that investment in the site would continue. Many said they were happy to travel to receive excellent, specialist care but wanted a 24/7 minor injuries and illness service to remain at Wycombe; this fed into ongoing discussions with clinicians, in what became an iterative process of service specification leading to a final set of proposals published in May 2012. 3 Consultation activity took many forms, including public meetings, online surveys, development of a website and production of a short video featuring interviews with lead clinicians. The aim was to engage with a wide range of stakeholders; these included patient groups, voluntary organisations and the public, as well as other health service staff. Alongside printed materials and a website, the BHiB team ran a 03
NHS Confederation The overview and scrutiny group could see first-hand how passionate the clinical staff were about change Clinical engagement was seen as vital local media campaign. Discussions were also held with local MPs, to hear their constituents views. The team also worked closely with the local authority s Health Overview and Scrutiny Committee, which set up its own working group to provide independent oversight for the local authority. This group attended site visits and met with groups of clinicians, as well as hearing presentations from the programme team. Though much of the engagement process was managed directly by the programme team, two independent companies were employed: one to facilitate engagement workshops, another to collate and analyse the mass of data received from meetings, surveys, press coverage and correspondence during the consultation process. Following each stage an independent report was produced, which provided important evidence of broad support for the proposals, which were also supported by the local PCT board. The resulting business case was therefore evidencebased and a combination of both clinical, and patient and public perspectives. Proceeding to implementation quickly was important, both to achieve improved clinical outcomes and to ensure that the public were not confused about what was happening. In November 2012, the Emergency Medical Centre at Wycombe Hospital closed and a new Minor Injuries and Illness Unit opened on-site. This was followed by the transfer of some inpatient medical wards and the creation of a new day unit and step-down ward. A wide-reaching communications programme, both internally and externally facing, was put in place to support the change. In 2012, BHiB won an Association of Healthcare Communications and Marketing award for its consultation and engagement programme. Although the BHiB programme is now closed, maintaining both dialogue with the public and clinicians, and the impetus for change under the new commissioning regime, are seen as vital. Members of local groups respected the fact that they got to talk to doctors rather than managers 04
We used minimal external consultancy, but lots of staff time Lessons for the future The team feels that the key to the success of the programme lay in four areas: the partnership between primary and secondary care, which enabled commissioners to work closely with acute clinicians on a plan for redesigning services clinical leadership of the engagement process, which helped reinforce the message that redesign was being pursued in order to improve services rather than save money work with GPs, to understand their individual concerns; instrumental in this was involvement from emerging clinical commissioning groups in the area the formation of a multi-agency project board, to ensure that the full spectrum of stakeholder views was represented. The comprehensive engagement exercise undertaken in Buckinghamshire means that the local community is now well informed about the issues and the case for change. As the new generation of healthcare commissioners takes over, there is a shared vision of the way forward across the local health economy. Further information: visit www.buckspct.nhs.uk/bhib References 1 Royal College of Physicians (2012) Hospitals on the Edge? The time for action. 2 www.buckinghamshire.nhs.uk/service-improvements/care-for-the-future/ 3 NHS Buckinghamshire and Oxfordshire Cluster (2012) Paper 12/41. Cluster Board Meeting May 2012: Consultation report. www.buckspct.nhs.uk/bhib 05
Service redesign case studies This NHS Confederation case study is part of a series designed to share good practice and lessons learned by local NHS organisations involved in major reviews of local health services. We are very grateful to Helen Peggs, Director of Communications, NHS Buckinghamshire and Lee Jones, Associate Director of Communications, Buckinghamshire Healthcare NHS Trust, for their participation in this case study and for providing the quotations used. To find out more about the series visit www.nhsconfed.org/reconfiguration The NHS Confederation The NHS Confederation represents all organisations that commission and provide NHS services. It is the only membership body to bring together and speak on behalf of the whole NHS. We help the NHS to guarantee high standards of care for patients and best value for taxpayers by representing our members and working together with our health and social care partners. We make sense of the whole health system, influence health policy, support the sharing and implementation of best practice and deliver industry-wide support functions for the NHS. Further copies or alternative formats can be requested from: Tel 0870 444 5841 Email publications@nhsconfed.org or visit www.nhsconfed.org/publications The NHS Confederation 2013. You may copy or distribute this work, but you must give the author credit, you may not use it for commercial purposes, and you may not alter, transform or build upon this work. Registered Charity no: 1090329 Stock code: CAS00301 The NHS Confederation 50 Broadway London SW1H 0DB Tel 020 7799 6666 Fax 0844 774 4319 Email enquiries@nhsconfed.org www.nhsconfed.org Printed on 100% recycled paper