Download Executive Summary

Epsom and St. Helier University Hospitals
NHS Trust
Shaping Our Future - 2012
An emergent strategy for Trust clinical services
Version 1.11 (24/01/08)
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
Document History
Version
Summary of Changes
1.0
1.1
Initial draft for discussion
Reformat and revision in relation to
comments received; addition of title and
contents pages.
Revised to reflect comments
Revised to reflect comments received
Redraft to focus on strategy rather than
business plan. Revisions to next steps.
Clarify strategy’s “emergent” status
Reflects comments in relation to v1.5
Reflects steering group comments and
discussions
Development of Next Steps
Reflects steering group comments and
discussions
Development of Next Steps
QA
Incorporation of additional steering group
comments in relation to draft v1.8
Board Draft amended to reflect comments
from Non-executive Director (Sue Marshal)
Board approved for distribution
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.8.1
1.9
1.10
1.11
Version 1.11
Page 2 of 41
Document
Status
Draft
Draft
By
Date
CI
KH
15/10/07
17/10/07
Draft
Draft
Draft
CI
KH
KH
17/10/07
06/11/07
07/11/07
Draft
Draft
Draft
CI
KH
KH
07/11/07
12/11/07
15/11/07
Draft
CI
17/11/07
Draft
Board
Draft
Board
Draft
Final
KH
KH
19/11/07
23/11/07
KH
14/01/08
KH
24/01/08
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
CONTENTS
EXECUTIVE SUMMARY ..................................................................................................... 4
Overall Vision .............................................................................................................. 5
Why will this be different? ........................................................................................... 10
INTRODUCTION ............................................................................................................... 12
Our process .................................................................................................................. 12
Our Vision ..................................................................................................................... 13
Local health profiles .................................................................................................... 15
Future health needs ..................................................................................................... 15
Local Commissioning Strategies ................................................................................ 16
Sutton and Merton PCT - The Better Healthcare Closer to Home Programme ....... 16
Surrey PCT - Surrey Fit for the Future Programme ................................................... 17
Responding to national best practice guidance ........................................................ 17
Other drivers for change ............................................................................................. 18
Delivering quality care today ...................................................................................... 19
Key Drivers for Change in Planned Care ................................................................ 19
The ideal model......................................................................................................... 20
Next Steps and Financial Implications ................................................................... 21
Acute Care .................................................................................................................... 21
Key drivers for change in acute care ...................................................................... 21
The ideal model......................................................................................................... 21
Next Steps and Financial Implications ................................................................... 24
Chronic Disease Management .................................................................................... 24
Key Drivers for Change in management of chronic disease ................................ 24
Ideal model ................................................................................................................ 24
Key Issues to be addressed .................................................................................... 25
Next Steps and Financial Implications ................................................................... 25
End of Life Care ............................................................................................................ 26
Key Drivers for change in End of Life Care ............................................................ 26
Ideal model ................................................................................................................ 26
Key Issues to be addressed .................................................................................... 27
Next Steps and Financial Implications ................................................................... 27
Women’s and Children’s Services .............................................................................. 27
Ideal model ................................................................................................................ 28
Maternity Care ........................................................................................................... 29
Children’s services ................................................................................................... 29
Outpatient Care ......................................................................................................... 29
Next Steps and Financial Implications ................................................................... 29
Conclusion ......................................................................................................................... 30
So how does it all add up? ................................................................................................. 30
NEXT STEPS .................................................................................................................... 31
APPENDIX A - Details of working group membership and wider engagement .................. 33
APPENDIX B - Epsom and St Helier Trust, Facts and Figures .......................................... 40
Version 1.11
Page 3 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
EXECUTIVE SUMMARY
This report sets out our emerging clinical vision for how services in the Trust should
develop over the next 10 years. It presents our aspiration to be the secondary care
provider of choice for the populations of Merton, Sutton, Epsom and surrounding areas. It
has been developed by our clinical workforce with valuable contributions from patients,
community providers and our commissioners. It also draws on the considerable work done
as part of the Better Healthcare Closer to Home Programme, as well as material produced
by NHS London to support “Healthcare for London – A Framework for Action” and by
Surrey PCT as part of their Fit for the Future Programme.
Purpose
The Clinical Strategy sets the direction of travel for the Trust’s clinical services and is a key
component in all service planning within the Trust. The diagram below shows how the
clinical strategy, together with external drivers, forms the basis for the Trust’s Annual Plan,
its internal supporting plans and individual objectives at all levels within the organisation.
Clinical Strategy
National Targets
Annual Plan
Commissioners’
Activity Volumes
and standards
Service-specific
Statutory / legal
changes /
NSF requirements
Division/Directorate
Annual Plans
Department/Team
Plans
Individual
Objectives
Individual
Objectives
Strategy Development Process
The process has been clinically led at all levels. The Steering Group was chaired by our
medical director, Lindy Steven. Supporting working groups were established for each of
the clinical areas covered by the Healthcare for London review. These were:
 Planned Care – chaired by Pieter LeRoux – Consultant Urologist
 Acute Care – chaired by Oliver Duke – Consultant Rheumatologist
 Long Term Conditions – chaired by Mashkur Khan – Consultant Physician
Version 1.11
Page 4 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
 End of Life Care – chaired by Andrew Hoy – Consultant in Palliative Medicine
 Women and Children’s Services – chaired by Norman McWhinney – Consultant
Obstetrician and Gynaecologist
The working groups had representation from all clinical disciplines; PPI (Patient and Public
Involvement) and staff forum representatives; the executive team including the Chief
Executive; the two main commissioning PCTs; and local community providers including
voluntary organisations. The full list of those involved is attached in Appendix A.
Strategic Context
Epsom and St Helier University Hospitals NHS Trust provides comprehensive secondary
acute hospital services for approximately 420,000 people living in parts of southwest
London and east Surrey. The Trust has two relatively small acute hospital sites, with 24hour A&E departments and acute inpatient beds, these are:
 Epsom General Hospital – serving 180,000 people in Surrey, and
 St Helier Hospital – serving 240,000 people from the London Borough of Sutton
and the southern part of the London Borough of Merton.
The Trust also operates the South West London Elective Orthopaedic Centre (SWLEOC)
– a joint venture with other south west London Trusts located on the Epsom General
Hospital site – and Sutton Hospital – adjacent to the Surrey branch of The Royal Marsden
Hospital; this houses a day surgery unit plus a range of diagnostic, rehabilitation and
outpatient services.
The Trust and its constituent hospitals face a complex array of strategic drivers.
Commissioners and Professional bodies are setting clearer and more demanding
standards for the provision of care. These create particular challenges for relatively small
acute hospitals. National policy is setting new organisational and professional priorities.
New technologies enable care to be delivered in different settings, by different people, and
in a more “joined up” fashion. We need to take all of these into account as we create our
own strategic vision. Crucially we have to recognise that this is a rapidly changing
environment – for example Surrey PCT has signalled its intention to commission acute
renal services from a Surrey provider and the emerging southwest London renal strategy
also indicates possible shifts of activity away from St Helier.
Practice Based
Commissioners in both Surrey and Sutton and Merton wish to see the majority of routine
diagnostics and outpatients delivered in community settings. Further work needs to be
undertaken to fully understand the implications of these potential changes and their
significance for the Trust. This document is therefore the beginning of a strategic
conversation, not the end.
Our work established a number of principles that should guide the care we deliver. These
principles have been used to guide the ideal and high level care pathways developed for
each area of care. The principles and care pathways are set out in supporting document –
Working Paper A.
An important message from many participants and one frequently echoed by patients is to
GET THE BASICS RIGHT. Having a foundation of high quality clinical care on which to
build our other aspirations must be a key objective.
Overall Vision
The Trust’s vision is to be the secondary provider of choice for the populations of Merton,
Sutton, Epsom and the surrounding areas. We provide services in many different settings,
Version 1.11
Page 5 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
serving diverse populations, but with one common goal – to provide the best care for our
patients.
Underpinning this goal we have four core values:1. Put the patient first
2. Work as one team
3. Respect each other
4. Strive for continuous improvement
This means delivering clinical excellence and a high quality experience for our patients in
all that we do, through: Focusing on the needs of our patients and empowering them to be active partners
in their care
 Research, innovation and continual improvement of productivity and efficiency
 Integration of our services with our partners in primary and tertiary care
 The safe delivery of care as close to home as possible.
We will forge strong partnerships with local primary and tertiary care providers to ensure
patients get care from the right person, in the right setting – first time. This will strengthen
our position as the secondary care provider of choice for our local population.
Delivering this vision will require a different range of actions in different clinical areas.
Summarised below are the particular visions and key priorities for action from each of the
working groups.
Planned Care
The vision for the future of planned care is:"To offer excellent, patient-focussed, evidence-based, elective care in the most
appropriate environment, with a more systematic and focused approach, separately
managed from the emergency workload."
This would include: Centres for excellence on the Epsom site building on the SWLEOC model



Beating hospital infections
High productivity and efficiency
High patient and staff satisfaction
 Consultant led hospital hubs for outpatient and day care supporting:




Community based spokes including routine diagnostics
Multi-disciplinary team working across primary and secondary care
Increased number of “one stop shops”
Teaching provided in all settings
Improved GP access to consultant advice e.g. through email and phone.
Acute Care
The vision for the future of acute care is:Version 1.11
Page 6 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
To provide rapid access to high quality specialist care for the acutely ill patient in a
clinically appropriate and safe environment as close to the patient’s home as possible.
Within this we will ensure rapid access to diagnostics and treatment for those with acute
care needs and appropriate specialist involvement for those with underlying chronic
disease.
The key elements are
 Collocation of primary care led urgent care facility and secondary care led
emergency care assessment in A&E
 24-hour provision of one stop rapid diagnosis and treatment
 Increased seniority of staff assessing and managing patients requiring emergency
hospital admission – ensuring appropriate treatment and referral for sub specialist
advice
 Increased use of care pathways and plans for patients with common or chronic
needs
 Effective monitoring and response to the needs of the acutely sick patient (in line
with NICE guidelines)
 Early discharge with community and social care support
The group spent some time considering how services could be best configured across our
two acute hospital sites. The preferred option is a tiered model, under which the majority
of acute medical care currently provided at Epsom would be sustained. This would include
critical care with the capacity to intubate patients until they have either stabilised or can be
moved to a more suitable facility. However, Epsom would not be expected to provide
services in relation to the following (the majority of these are already excluded and are
referred to other centres offering specialist services):
 Myocardial Infarction showing an ST wave elevation1 (potential benefit from primary
angioplasty) – majority of patients diagnosed by ambulance paramedics are already
taken directly to hospitals offering 24-hour primary angioplasty treatments
 Head Injury – Again patients with severe head injuries are routinely taken directly to
neuroscience centres
 Acute Stroke needing thrombolysis – increasingly, patients who have suffered a
stroke will be taken directly to centres offering 24-hour thrombolysis
 Acute renal failure – currently, patients suffering acute renal failure are transferred
to the Renal Department at St Helier
 Massive fresh GI (gastro-intestinal) bleed. Patients presenting with massive GI
bleeds may require emergency surgery and are therefore transferred to St Helier.
Further work is needed to understand the out-of-hours diagnostic support required at
Epsom under his model.
St Helier would retain the majority of its current services including intensive care beds
backed up by 24/7 imaging including CT and laboratory services.
1
An electrocardiogram (ECG) tracing consists of a number of peaks and troughs referred to by letters of the
alphabet from P to U. A typical ECG tracing of a normal heartbeat (or cardiac cycle) consists of a P wave, a
QRS complex and a T wave. A small U wave is normally visible in 50 to 75% of ECGs. The ST segment is
that part of the tracing between the S trough and T peak. Flat, downsloping, or depressed ST segments may
indicate coronary ischemia. ST segment elevation may indicate myocardial infarction.
Version 1.11
Page 7 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
Chronic Disease Management
The vision for the future of chronic disease is:A fully integrated service with the patient at the centre; a service that improves the
patient’s independence; a service that bridges the primary and secondary care divide; a
service that looks beyond buildings in order to provide the best quality care for our
patients.
Key areas for action:





Increased training and support for community based professionals
Increased provision of rapid access clinics or advice to GPs
Improved advice for patients on their condition and how to manage it
Improved advice for patients and GPs on their medication and equipment
Improved access to diagnostics and expert advice
Increased use and dissemination of care plans
End of Life Care
Our aim is to provide care at the end of life that
 Ensures individuals are treated with dignity and respect
 Supports individual choice through an end of life plan that includes preferences on
place of death
 Helps people be free from pain and other symptoms
 Enables people to be in the company of close family and friends
To deliver this we need to
 Embed the use of good practice set out in the Liverpool Care Pathway and Gold
Standards Framework approaches in both primary and secondary care
 Ensure improved access to education and communication skills training
 Create stronger links, including joint posts, with hospices, primary and community
care to avoid admission and facilitate discharge.
Women and Children
The working group has set out an approach to individualised care which should strengthen
quality and outcomes.
 Empowering women to make choices – who treats them, where they are treated –
promoting home births
 A systematic approach to risk assessment during pregnancy and birth
 Improve access to paediatric and maternity clinics – timing, fast track options,
location
 Increased information and education for patients
 Increase the level of consultant and midwife input in maternity care
 Increase the level of specialist nursing input in paediatrics
 Opportunities for closer working with primary care – e.g. in paediatric clinics and
A&E
Version 1.11
Page 8 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
 Improving the quality of facilities to meet NSF standards and patients’ expectations
Women’s and children’s services face particular challenges. There are deficits in staffing at
both sites – with a growing need to expand staffing to meet commissioner and national
minimum standards. The expert panel, convened last year as part of the Safety and
Sustainability review, concluded that the best way to resolve these deficits would be to
concentrate inpatient maternity and paediatric services on one site. This conclusion had
considerable but not universal support from the working group. There were differing views
about which site inpatient services should be concentrated on. The programme of public
engagement and strategy work planned with Surrey and Sutton and Merton PCTs should
help clarify these issues and suggest a way forward. The programme will include
significant public engagement in east Surrey and Sutton and Merton. The programme is
expected to begin in late autumn 2007 with the case for change delivered by spring 2008.
Any resultant consultation process would then take place summer 2008. Timelines for the
delivery of projects and benefits will be set out in the Case for Change that will be
developed following the engagement process.
So how does it all add up?
Delivering the vision
Forging strong partnerships with local primary and tertiary care providers will strengthen
our position as secondary care provider of choice for the populations of south Merton,
Sutton, Epsom and the surrounding areas.
The diagram below sets out a tiered approach which would retain the majority of current
acute medical care on the Epsom site. This is a model which requires significant further
work, and no changes in existing services are anticipated in advance of public
engagement and consultation. The purpose is to help people visualise the future as a
contribution to the wider strategic debate.
Epsom
St Helier
A&E & Primary care led
A&E & Primary care led
urgent Care
Acute Medicine – Defined
No acute surgery or trauma
Elective Surgery - Majority
HDU flex to ITU
Obstetrics ?=>Low risk or
Ambulatory*
Paediatrics ?=> assessment*
24/7 Diagnostics
Outpatients with primary care
input
urgent Care
Acute Medicine
Acute surgery and trauma
Elective Surgery – some
complex
HDU & ITU
Obstetrics (=> 98 hours
cover)*
Paediatrics*
24/7 Diagnostics
Outpatients with primary care
input
Version 1.11
Page 9 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
* Subject to consultation
Workforce development will be a key enabler for the delivery of the strategy. This applies
to all clinical disciplines but particularly to nursing. Clinical staff need to be equipped to
take on new roles and responsibilities and work in different settings – and be provided with
career structures that reward their skills and experience. Nurses are likely to lead clinical
activity in many settings and so development of leadership skills for this group will be
particularly important.
Conclusion
Much of what we describe can be acted upon now and deliver immediate benefits for
patients. Some elements will require a much longer time frame for delivery.
Our first priority is to understand the affordability of the models and their viability in
workforce terms. This is a particular issue for the acute medical model and we will need
further clinical input to this appraisal. We will need to consider the estates implications and
any immediate barriers to implementation of the models.
We will use the work to help frame the Trust’s Annual Business Plan and will be engaging
with each Division and the PCTs to identify areas where we an make rapid progress to
improve services for patients. Whilst the affordability of the main elements has yet to be
determined, there are a number of issues that could be taken forward during the coming
year and these should be identified in the business plan and considered as part of SLA
negotiations.
Why will this be different?
As a multi-site Trust, incorporating two relatively small acute hospitals, we have been
involved in several strategic reviews over the past 10 years; some which we have led and
some which have been led by others. In common with similar Trusts, we have too often
failed to generate agreement on the way forward across our sites and this has undermined
progress in the implementation of improvements.
We continue to be involved in the Better Healthcare Closer to Home programme and the
Surrey Fit for the Future programme; and the outcomes of the forthcoming consultation on
the Darzi proposals for London will undoubtedly influence our future. It is important that we
are able to influence wider strategic planning programmes, and to do this we need to have
a clear and common understanding of our aspirations, as individual clinicians, clinical
teams and as an organisation.
This report is the first step in developing that common understanding. We do not expect to
achieve an immediate consensus on all issues, nor do we expect to satisfy everybody’s
wants and desires. But we do need to have a healthy debate about the choices open to us;
to explore the options for meeting the challenges we face and explain clearly how we will
make decisions and why we have chosen a particular path. We need to do this through a
process that engages our staff, our patients and the wider public living in the areas we
serve; recognising that proposals for significant changes in services will require formal
public consultation before they can proceed.
In this document, we have tried to set out the key drivers influencing change in each
service area and we have presented the views of those clinicians who took part in the
clinical working groups. No one person has all the answers and, if you feel that we have
Version 1.11
Page 10 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
not taken particular issues into account, or you feel that there are better solutions to the
ones proposed here, we wish to hear from you.
Please send comments to:
Keith Hider
Head of Strategy
St Helier Hospital
[email protected]
Version 1.11
Page 11 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
INTRODUCTION
1. This report sets out our vision for how services in the Trust should develop over the
next 10 years. Much of what we describe can be acted upon now and deliver
immediate benefits for patients. Some elements will take a much longer time frame for
delivery. In all that we do, we need to recognise a rapidly changing environment. A
significant part of our challenge is to build flexibility into our services, workforce and
facilities.
PURPOSE
2. The Clinical Strategy sets the direction of travel for the Trust’s clinical services and is a
key component in all service planning within the Trust. The diagram below shows how
the clinical strategy, together with external drivers, forms the basis for the Trust’s
Annual Plan, internal supporting plans and individual objectives at all levels within the
organisation.
Clinical Strategy
National Targets
Annual Plan
Commissioners’
Activity Volumes
and standards
Service-specific
Statutory / legal
changes /
NSF requirements
Division/Directorate
Annual Plans
Department/Team
Plans
Individual
Objectives
Individual
Objectives
Our process
3. The process has been clinically led at all levels. The Steering Group was chaired by
our medical director, Lindy Steven. Supporting working groups were established for
each of the clinical areas covered by the Healthcare for London Review.
 Planned Care – chaired by Pieter LeRoux – Consultant Urologist
 Acute Care – chaired by Oliver Duke – Consultant Rheumatologist
Version 1.11
Page 12 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
 Long Term Conditions – chaired by Mashkur Khan – Consultant Physician
 End of Life Care – chaired by Andrew Hoy – Consultant in Palliative Medicine
 Women and Children’s Services – chaired by Norman McWhinney – Consultant
Obstetrician and Gynaecologist
4. The working groups had representation from all clinical disciplines; PPI (Patient and
Public Involvement) and staff forum representatives; the executive team including the
chief executive; the two main commissioning PCTs; and local community providers
including voluntary organisations. The full list of those involved is attached in Appendix
A.
5. Work was undertaken from August – October 2007, but has also drawn and built on the
considerable body of work that fed into the Better Healthcare Closer to Home
Programme, as well as all the material produced by NHS London to support
“Healthcare for London – A Framework for Action”.
6. Our work has developed a vision for the future that is about the way we will deliver
services; not about buildings. It has established a number of principles that have been
used to guide the ideal and high level care pathways developed for each area of care.
The principles and care pathways are set out in supporting document – Working Paper
A.
Our Vision
7. The Trust’s vision is to be the secondary provider of choice for the populations of
Merton, Sutton, Epsom and the surrounding areas. We provide services in many
different settings, serving diverse populations, but with one common goal – to provide
the best care for our patients.
8. Underpinning this goal we have four core values as an organisation:o Put the patient first
o Work as one team
o Respect each other
o Strive for continuous improvement
9. This means delivering clinical excellence and a high quality experience for our patients
in all that we do, through: Focusing on the needs of our patients and empowering them to be active partners
in their care
 Research, innovation and continual improvement of productivity and efficiency
 Integration of our services with our partners in primary and tertiary care
 The safe delivery of care as close to home as possible.
10. We will forge strong partnerships with local primary and tertiary care providers to
ensure patients to get care by the right person, in the right setting – first time. This will
strengthen our position as the secondary care provider of choice for our local
population.
Version 1.11
Page 13 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
11. Whilst planning our future, we must also deliver high quality services today. The
Trust’s priorities for this year have clearly been identified as:
 Clinical Service Delivery
Delivering performance (Infection control, Emergency Access, Waiting times,
Financial Plan)
 Improving the patient experience
Infection control, privacy and dignity, learning from incidents
 Improving staff experience
Employee relations, employee experience
 Setting out a direction of travel
Internal clinical strategy, working with both PCTs.
ORGANISATIONAL CONTEXT
12. Epsom and St Helier University Hospitals NHS Trust provides comprehensive
secondary acute hospital services for approximately 420,000 people living in parts of
southwest London and east Surrey. The Trust also provides more specialist renal,
pathology and neonatal intensive care services to a wider catchment, including parts of
west Surrey, Sussex and Hampshire.
13. The Trust has two relatively small acute hospital sites, with 24-hour A&E departments
and acute inpatient beds, these are:
 Epsom General Hospital – serving 180,000 people in east Surrey, and
 St Helier Hospital – serving 240,000 people from the London Borough of Sutton
and the southern part of the London Borough of Merton.
14. Both sites have buildings that require significant investment to make them fit for 21 st
century healthcare delivery. The Better Healthcare Closer to Home programme aims
to address this in developing a business case for estate renewal.
15. Some of the inpatient services are configured to be provided from one site only; e.g.
emergency surgery, neonatal high dependency and acute renal inpatient services are
centred on the St Helier site.
16. 92% of inpatient beds, and 77% of inpatient admissions arise from patients admitted as
an emergency. 8% of beds, 23% of admissions are for planned patients, 73% of these
are managed as day cases.
17. The Trust also operates
 The South West London Elective Orthopaedic Centre (SWLEOC) – located on
the Epsom General Hospital site; the centre provides orthopaedic services to
patients of St George’s Healthcare NHS Trust, Mayday Healthcare NHS Trust and
Kingston Hospital NHS Trust in addition to patients from our own Trust.
 Sutton Hospital – adjacent to the Surrey branch of The Royal Marsden Hospital;
this houses a day surgery unit plus a range of diagnostic, rehabilitation and
outpatient services
Version 1.11
Page 14 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
18. Further services are provided through community hospitals controlled and managed by
Sutton and Merton PCT, Central Surrey Health and independent sector partners.
These include day surgery, a range of outpatient clinics and intermediate care services.
Local health profiles
19. The Trust serves a relatively healthy population, but from a widely varying context. To
the north we serve a densely populated urban environment, while to the south a more
sparsely populated suburban and more rural setting.
 East Surrey – relatively old and more affluent population with healthier lifestyles
than the national average. Death rates due to heart disease and cancer significantly
lower than national average.
 Merton – The poorest and most densely populated area we serve. The wards in the
south and east of the borough are most deprived but none in national lowest
quartile (most in second quartile). Despite this, population tend to eat healthily and
have low levels of binge drinking and obesity. Deaths due to cancer, heart disease
and stroke are similar to the national average.
 Sutton – Population age similar to national average. Relatively healthy, with low
levels of deprivation. The wards in east and north of borough are more deprived but
none in national lowest quartile. There is relatively poor air quality and poor quality
housing. Deaths due to cancer, heart disease and stroke are similar to the national
average.
20. More facts and figures about the Trust and its services are provided in Appendix A.
STRATEGIC CONTEXT - WHY SERVICES NEED TO CHANGE
21. The Trust faces a complex array of strategic drivers. Commissioners and Professional
bodies are setting clearer and more demanding standards for the provision of care.
These create particular challenges for relatively small acute hospitals. National policy is
setting new organisational and professional priorities. New technologies enable care to
be delivered in different settings, by different people, and in a more joined up fashion.
We need to take all of these into account as we create our own strategic vision. Some
of the most significant of these are described below. Crucially we have to recognise
that this is a rapidly changing environment.
Future health needs
22. The local population is expected to remain relatively stable. In common with much of
the rest of the country, the Trust’s catchment population is generally ageing (driven by
the post-war baby boom) and is therefore subject to increasing levels of chronic
disease. Musculoskeletal, diabetes and renal disease are anticipated to experience
some of the greatest increases.
23. Using local population projections, the projected change in our catchment population
up to 2012 would translate into a need for a small increase in adult beds (25 to 30) and
broadly the same number of children’s beds as today. This assumes no change in
admission rates and lengths of stay. Given both are expected to fall with new models of
care, this suggests a fall in the number adult beds required in the future.
Version 1.11
Page 15 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
Local Commissioning Strategies
24. Our two local PCTs and London SHA are all undertaking major strategic reviews.
A Framework for Action – London SHA Strategy Consultation
25. "A Framework for Action" sets out some principles and models for health care provision
in the future. It suggests improvements in the following areas: Staying healthy – underlining prevention is better than cure
 Maternity and newborn care – where a minimum of 98 hours of consultant presence
is recommended
 Children – suggesting local access to paediatric assessment but more consolidation
of paediatric inpatient units
 Mental Health – greater focus on the young and those most at risk
 Acute Care – seeking better access to diagnostics and urgent care locally and
greater centralisation of complex acute care e.g. stroke and trauma care
 Planned Care – suggesting outpatient and diagnostics are devolved to more local
settings
 Long Term Conditions – better information for patients and multi-disciplinary
working across primary, community and hospital care to avoid unnecessary
admissions
 End of Life Care – better support for patients’ choice of where they die and
improved packages of care for patients at the end of life.
26. Some of the proposed models of care provision are: Polyclinic – serving a population of around 50,000. They would offer a greater
range of services than traditionally provided in GP practices including the majority of
outpatient consultations and routine diagnostics.
 Local Hospital – serving a population of around 250,000 with an A&E - would
provide the majority of non-complex inpatient care
 Elective Centre – would deliver most high throughput planned surgery – SWLEOC
is cited as an example
 Major Acute Hospital – serving a population of 0.5 – 1m - handling the most
complex inpatient care including major trauma
27. The models of care are expected to facilitate care delivery according to the principles of
change. For example the polyclinic should enable a significant proportion of current
outpatient and diagnostic care to be delivered more locally and in a more integrated
way. The models and principles of care will be the subject of public consultation which
is expected to reach a conclusion by May 2008.
Sutton and Merton PCT - The Better Healthcare Closer to Home Programme
28. The Better Healthcare Closer to Home programme shares the ambition of a Framework
for Action of delivering more care in GPs surgeries and other community care settings.
The programme began with a vision of reproviding all the Trust's inpatient services
(from Epsom and St Helier hospitals) in a new hospital on the Sutton site while
devolving the majority of outpatient and day case services into local settings. This
vision has proved unaffordable. The programme is still building a business case for
renewing the Trust's estate and developing local care facilities in Sutton and Merton.
Surrey PCT Is working separately with the Trust to determine the scope and scale of
services at Epsom Hospital and supporting local care facilities, see below.
Version 1.11
Page 16 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
29. Since the option to build a new hospital on the Sutton Hospital site has been found to
be unaffordable, a key issue to be addressed as part of the next phase of planning will
be the future of clinical services currently delivered from that site. This work will be
taken forward with stakeholders with an interest in the site (South West London and St
George's Mental Health NHS Trust, Sutton and Merton PCT, The Royal Marsden
Hospital Foundation Trust and others) to determine which services can remain in local
care settings (some of which may remain in facilities at Sutton) and which need to be
configured across the Epsom and St Helier hospital sites.
Surrey PCT - Surrey Fit for the Future Programme
30. The Fit For the Future (FFF) programme has adopted an evidence based approach to
improving clinical standards. The seven areas of acute service delivery examined by
Fit For the Future are:
 Vascular Services
 Cardiac Services
 Renal Services
 Maternity Services
 Paediatric Services
 Stroke Services
 Emergency Surgery Services
31. For each of these areas, Surrey Primary Care Trust has developed a set of
‘commissioning intentions’ based on national and international clinical evidence. These
set out the clinical standards expected of hospitals providing each of the seven
services. Epsom and St Helier Trust is working with Surrey PCT to ascertain how we
can comply with these standards and whether compliance will require us to reconfigure
their services. Our initial response has been that the standards set for maternity,
paediatric and stroke services may require service reconfiguration.
32. The Trust will also be undertaking a significant programme of work on renal services.
The PCT has signalled their intention to commission acute renal services from a Surrey
provider and this would have a significant impact on the Trust. In addition, the
emerging southwest London renal strategy also indicates possible shifts of activity
away from St Helier.
Responding to national best practice guidance
33. During the time that we have been undertaking the clinical strategy work, the Royal
Medical Colleges have published three important pieces of guidance on the future
delivery of hospital services.
1. Acute Health Services (September 2007) Report of a working party of the Academy
of Medical Royal Colleges2
Like Lord Darzi, the Academy suggests a more tiered approach to acute care.
Their report also talks about “local hospitals” – and suggests they should have an
A&E but a smaller range of 24/7 services. As a minimum this would include acute
medical services and intensive care services. The Academy anticipates the
2
http://www.aomrc.org.uk/documents/Acutehealthcareservicesreportofaworkingparty2.pdf
Version 1.11
Page 17 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
withdrawal of consultant led obstetrics and inpatient paediatric services from
smaller hospitals.
2. Modelling the future (September 2007) Royal College Paediatrics and Child Health3
The report argues that given the limited number of qualified medical staff in
paediatrics now and in the future, smaller units should close to support safe staffing
levels in larger units. It suggests that paediatric services should be networked and
access to urgent assessment sustained at a local level.
3. Safer Childbirth – Minimum Standards for the organisation and care of delivery
(October 2007) Royal College of Obstetricians and Gynaecologists, Royal College
of Midwives, Royal College of Anaesthetists, Royal College of Paediatrics and Child
Health4
This sets minimum standards for consultant obstetrician, midwife, paediatric and
anaesthetic cover. The Colleges recommend that any unit (whatever size) that
accepts high risk pregnancies should have at least 40 hours of consultant labour
ward presence. Smaller units (<2,500 births) which only take low risk births need to
undertake a risk assessment to ensure the appropriate level of consultant cover.
Other drivers for change
34. An important driver for change, underlined heavily in “A Framework for Action”, is the
need to respond better to the needs of patients. We know from surveys of our own
patients that there are areas where we need to do better:
 Involving people more in decisions about their care
 Providing them with better information – especially on discharge
 Improving the quality of hospital food.
35. Increased choice for patients means that, if we do not address these issues, patients
will vote with their feet and the trust will lose income. Conversely if we can improve the
quality of care we can gain income and grow services.
36. The aspiration to deliver care more locally is facilitated by new technologies and new
ways of working. Diagnostic equipment is reducing in size and cost enabling many
diagnostic procedures to be done outside a hospital setting. GPs and specialist nurses
are acquiring the skills that enable many patients with chronic disease to have their
care managed at home or in a community setting.
37. Workforce development will be a key enabler for the delivery of the strategy. This
applies to all clinical disciplines but particularly to nursing. Clinical staff need to be
equipped to take on new roles and responsibilities and work in different settings – and
be provided with career structures that reward their skills and experience. Nurses are
likely to lead clinical activity in many settings and so development of leadership skills
for this group will be particularly important.
3
4
http://www.rcpch.ac.uk/Health-Services/ServiceReconfiguration/Modelling-the-Future
http://www.rcog.org.uk/resources/public/pdf/safer_childbirth_report_web.pdf
Version 1.11
Page 18 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
38. To achieve truly integrated care, work is required to break down professional
demarcations between secondary and primary care clinicians; to plan care in a coordinated way and maximise the contribution of the entire workforce.
39. Ultimately the electronic health record should enable health and other professionals to
deliver truly patient focused and integrated care. In the meantime, progress in
developing the electronic sharing of pathology results, x-rays, prescriptions and
summaries of inpatient and outpatient episodes, will help us along that path.
40. Finally all hospitals in England face significant challenges as a result of the new limits
to junior doctor working hours set by the European Working Time Directive, and the
new training patterns created by Modernising Medical Careers. Both these drive a
need to have consultant delivered rather than consultant led services. This can bring
great gains in the quality of clinical care but requires a significant critical mass of
activity and doctors for this to be delivered cost effectively.
HOW WE CAN DELIVER OUR VISION
Delivering quality care today
41. The clinical strategy sets out a vision for the way services will be delivered in the future
and provides direction to the development of the Trust and its services. However,
success in the future must be built on sound foundations today. Delivering on our core
priorities and a strong customer focus is essential if we are to attract patients to use our
services and secure the income we need to fund our development plans. Patients’
priorities therefore need to be our priorities and this is often about getting the basics
right.
Planned Care
42. The Working Group proposals for the improvement of planned care build on the model
first developed within the Better Healthcare Programme and subsequently laid out by
NHS London in a “Framework for Action”. The model suggests a more systematic and
focused approach to elective care, separate from the emergency workload.
Key Drivers for Change in Planned Care
43. National policy and local strategies are driving four significant changes in the provision
of planned care.
 The concentration of more specialised and complex care onto fewer sites.
 An increased capacity to undertake surgical procedures as day cases or 23 hour
stays.
 The dispersal of routine outpatient and diagnostic services into more local settings
 An increasing focus on multi-disciplinary working and networks of care.
44. In addition, the encouragement of patient choice, supported by information on quality
and outcomes, underlines to imperative to achieve clinical excellence in all that we do.
The benefits of this approach have already been seen in the South West London
Elective Orthopaedic Centre, where low MRSA rates and high quality care are
encouraging patient flows from a wide geographical area.
Version 1.11
Page 19 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
The ideal model
45. The vision for the future of planned care is :"To offer excellent, patient focussed, evidence based elective care in the most appropriate
environment, with a more systematic and focused approach, and separately managed
from the emergency workload."
46. The group considered a number of options for the configuration of elective services and
developed an ideal high level care pathway for elective care (see supporting working
paper A). It recommends the following:Develop elective centres of excellence on the Epsom site, building on the
SWLEOC model  Beating hospital infections
 High patient and staff satisfaction
 High productivity and efficiency
47. The working group recommend that Epsom act as the focus for elective work in the
Trust. The experience from SWLEOC and after the S2 surgical changes suggests that
this is a viable model. Elective activity should promote day case and 23 hour stays
where possible.
48. Optimising the pre-operative pathway is seen as key to achieving successful
admission, treatment, early discharge and clinical outcomes and should be a focus for
further multi-disciplinary and multi-organisational work.
49. The group envisaged a modular approach on the Epsom site. This would enable each
service to develop its own distinctive identity, following the model established by
SWLEOC. This would also facilitate the site acting as an elective hub for services from
a number of Trusts and extend this to Surrey as well as South West London. The
group was also keen to see links strengthened with the Royal Marsden to reap some of
the clinical benefits anticipated originally for the critical care hospital on the Sutton site.
50. Outpatient and day case services should be delivered through a network of facilities
including consultant-led hospital hubs with: Community based spokes for outpatient assessment and follow up including routine
diagnostics
 Multi-disciplinary team working across primary and secondary care
 Increased number of “one stop shops”
 Teaching provided in all settings
 Improved GP access to consultant advice e.g. through email and phone.
51. The following types of clinic are likely to be more appropriate for a hub setting, rather
than a spoke: cancer clinics; complex therapy clinics or clinics which use high cost
equipment.
52. The BHCH programme is already building the business case for a polyclinic on the St
Helier site and exploring the feasibility on the Sutton site. Epsom GPs have also
expressed enthusiasm for such a development on the Epsom site.
Version 1.11
Page 20 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
53. The working group recognised that while some surgical day case work would benefit
from concentration on one site, many medical day cases would not. Further work
needs to be done to identify opportunities for increased concentration of surgical day
case work.
Next Steps and Financial Implications
54. Align these proposals with work underway as part of the recovery programme – in
particular work on length of stay and theatre efficiencies.
55. To develop a business case to support any prospective shifts in activity between sites
and expand capacity in order to offer services to other commissioners and develop
collaborative opportunities with other providers, as with SWLEOC. This also needs to
reflect shifts in the management of care, from inpatient to 23 hour stay and from day
case to outpatient/primary care procedures. Any work would need to ensure
appropriate stakeholder engagement and consultation.
Acute Care
56. The working group considered the many challenges facing acute services and believes
that it has identified a model of care which addresses these challenges and delivers a
significant improvement in the quality of care. However, further work needs to be done
to assess the financial viability of the model and work out in more detail the clinical
case mix and staff mix needed at each hospital site.
Key drivers for change in acute care
57. National policy and local strategies are driving significant changes in the provision of
acute care.
 The concentration of more specialised and complex care onto fewer sites.
 A shift from consultant led to consultant delivered care with more senior
assessment early in the care pathway
 Development of urgent care networks that bring secondary and primary care
together to provide urgent and emergency care
 A more proactive approach built on risk identification especially in those with
chronic disease.
The ideal model
58. The vision for the future of acute care is:To provide rapid access to high quality specialist care for the acutely ill patient in a
clinically appropriate and safe environment as close to the patient’s home as possible.
Within this we will ensure rapid access to diagnostics and treatment for those with acute
care needs and appropriate specialist interest for those with underlying chronic disease.
59. The ideal care pathway for acute care is laid out in supporting working paper A. The
key elements are:
 Co-location of primary care led urgent care facility and secondary care led
emergency care assessment in A&E
 24-hour provision of one stop rapid diagnosis and treatment
 Increase the seniority of staff assessing and managing patients requiring
emergency hospital admission – ensuring appropriate treatment and referral for sub
specialist advice
Version 1.11
Page 21 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
 Increased use of care pathways and plans for patients with common or chronic
needs
 Effective monitoring and response to the needs of the acutely sick patient (NICE
guidelines)
 Early discharge with community and social care support
60. The staffing of these elements would differ depending on the profile of acute services
available on the site. The group’s view was that on a site with the full range of acute
services there was a strong argument for an A&E/Emergency Department staffed by
specialists in emergency medicine who would undertake the immediate assessment
and management of the acutely sick patient before referral on to the appropriate
specialist team. In a hospital with a more limited range of acute services, as at Epsom,
there is a case for integrating the emergency medicine and acute medical teams and to
create one unified assessment facility. The diagram below attempts to illustrate patient
flows and relationships of the various elements. Further work is needed on this, in
particular how paediatric assessment should be built into both models.
Unscheduled medical care – patient flows and
departmental adjacencies
Diagnostics
GP
Referral
Navigator
Self
Referral
Primary
Care
Centre
CAU
CDU
Medical
Inpatient
Wards
Emergency
department
Blue
Light
Resuscitation
Inward routes
Outward routes
Diagnostic routes
HDU
61. The group spent some time considering how services would be best configured across
our two acute hospital sites. The status quo was not supported as an option. GPs in
Sutton and Merton and Surrey wish to see a different model of care for A&E at both
Epsom and St Helier. There was also consensus that the current model does not
deliver best care for the acutely unstable patient or those with complex chronic needs.
62. Benefits were seen to a centralised model. It could create a greater critical mass of
trained doctors to support A&E and acute medical and critical care services. However
it would also result in a significant loss of access to patients and income to the Trust.
Version 1.11
Page 22 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
63. The preferred option that the group wishes to explore further is the tiered model (see
diagram below). Under the “tiered” model, the majority of acute medical care provided
at Epsom would be sustained including critical care and the capacity to intubate
patients until stable, but Epsom would not be expected to provide the following
(majority of these are already excluded):
 Myocardial Infarction showing an ST wave elevation5 (potential benefit from primary
angioplasty) – majority of patients diagnosed by ambulance paramedics are already
taken directly to hospitals offering 24-hour primary angioplasty treatments
 Head Injury – Again patients with severe head injuries are routinely taken directly to
neuroscience centres
 Acute Stroke needing thrombolysis – increasingly, patients who have suffered a
stroke will be taken directly to centres offering 24-hour thrombolysis
 Acute renal failure – currently, patients suffering acute renal failure are transferred
to the Renal Department at St Helier
 Massive fresh GI (gastro-intestinal) bleed. Patients presenting with massive GI
bleeds may require emergency surgery and are therefore transferred to St Helier.
Epsom
St Helier
A&E & Primary care led
A&E & Primary care led
urgent Care
Acute Medicine – Defined
No acute surgery or trauma
Elective Surgery - Majority
HDU flex to ITU
Obstetrics ?=>Low risk or
Ambulatory*
Paediatrics ?=> assessment*
24/7 Diagnostics
Outpatients with primary care
input
urgent Care
Acute Medicine
Acute surgery and trauma
Elective Surgery – some
complex
HDU & ITU
Obstetrics (=> 98 hours
cover)*
Paediatrics*
24/7 Diagnostics
Outpatients with primary care
input
*Subject to consultation
64. Further work is required to understand the out-of-hours diagnostic support required at
Epsom under this model.
5
An electrocardiogram (ECG) tracing consists of a number of peaks and troughs referred to by letters of the
alphabet from P to U. A typical ECG tracing of a normal heartbeat (or cardiac cycle) consists of a P wave, a
QRS complex and a T wave. A small U wave is normally visible in 50 to 75% of ECGs. The ST segment is
that part of the tracing between the S trough and T peak. Flat, downsloping, or depressed ST segments may
indicate coronary ischemia. ST segment elevation may indicate myocardial infarction.
Version 1.11
Page 23 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
65. St Helier would also retain the majority of its current services including intensive care
beds backed up by 24/7 imaging including CT and laboratory services.
66. Stroke and cardiac services need further investment and development as part of a
strong cardiovascular service including local provision of cardiac catheterisation and
pacing facilities at St Helier. Patients requiring specialist intervention, for example for
primary percutaneous coronary intervention, would be treated at St George’s, St
Thomas’ or the Royal Brompton Hospital and then rapidly transferred back to St Helier
or Epsom to complete their treatment.
67. Under this option both Epsom and St Helier would support the development of primary
care led urgent care centres alongside the current A&E departments. Epsom would
develop a more integrated approach to clinical assessment and have a facility staffed
jointly by emergency and acute physicians. It is recognised that this would require
support for training and competence development in both medical and nursing staff.
Next Steps and Financial Implications
68. Align these proposals with work underway as part of the recovery programme – in
particular work on length of stay and workforce.
69. Do headline assessment of cost and revenue implications of proposed model. If
financially viable and supported by the outcome of the “Framework for Action”
consultation, prepare business case for implementation in conjunction with local
primary care trusts. Ensure supporting public engagement and note that it will be
subject to any required public consultation.
Chronic Disease Management
70. The working group supported many of the aspirations of Our Health, Our Care, our Say
(Department of Health, 2006) and the Framework for Action published by London SHA
July 2007. The group has laid out a programme of action which if implemented should
drive a step change in the quality of care. Some of the recommendations apply to the
Trust but some apply to the PCT and supporting community services. Change is
needed in all areas if we are to deliver the vision as laid out.
Key Drivers for Change in management of chronic disease
71. National policy and local strategies are driving change in the way we care for people
with chronic disease. Key factors are: Growing numbers of people with one or more long term health conditions, many
with accompanying social care needs
 Increased focus on prevention and proactive case management
 New technologies and new roles provide an increased capacity to treat people at
home or in a community setting.
Ideal model
72. The vision for the future of chronic disease is:A fully integrated service with the patient in the centre; a service that improves the
patient’s independence; a service that bridges the primary and secondary care divide; a
Version 1.11
Page 24 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
service that looks beyond buildings in order to provide the best quality care for our
patients.
73. To achieve this we wish to create a network of specialists working in partnership with
primary and community care clinicians to deliver high quality, patient focused care. We
will increase the use and dissemination of care plans; either in the form of patient-held
records or the use of an integrated electronic patient record accessible to both primary
and secondary care.
74. Our aim is to deliver the majority of care in the community and use proactive and
preventative approaches, including active support for self care, to minimise the use of
hospital based services and maintain independence. However, we need to guarantee
hospital access when a patient has an unstable condition and we need to offer a rapid
one stop diagnostic treatment facility with early discharge and ambulatory care support.
This can be done by specialist outreach teams who also have a firm base in the acute
sector.
75. Community matrons and specialist nurses will play an important role in chronic disease
management and will benefit from training and collaboration with secondary care. We
will continue to develop partnership and integrated work with social services and
voluntary sector organisations as well as patients and their carers to maximise
resources and support the management of chronic disease.
76. The generic model of care is laid out in the care pathway in the supporting working
paper A which also includes exemplar pathways for respiratory disease, diabetes and
dermatology.
Key Issues to be addressed
77. The group has identified a number of key issues that need to be addressed in order to
deliver our vision. Many of these echo the actions identified in the “Framework for
Action” (July 2007). They are:
 Training and support for community based professionals
 Improved access to rapid access clinics and advice for GPs and expert patients
 Improved information and advice for patients and their carers on their condition and
self-management
 Improved advice for patients and GPs on medication and equipment
 Improved access to diagnostics
 Increased use and dissemination of care plans
Next Steps and Financial Implications
78. Further multi-disciplinary and multi-organisational work is required to improve rapid
access to services and facilitate greater patient independence through improved
information, access to advice and development of ‘expert patient’ self-management
programmes. Detailed proposals are laid out in the supporting working papers.
Version 1.11
Page 25 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
End of Life Care
79. The proposals for the improvement of End of Life Care build strongly on the ideas laid
out in the Darzi Report – A Framework for Action. Our strategy goes further in seeking
to integrate far more completely the acute, community, hospice and care home sectors.
We have made a number of recommendations about how care could be improved for
people requiring end of life care (EOLC) who use our Trust. Some of these
recommendations apply to the Trust but some apply to the PCT and supporting
community services. Change is needed in all areas if we are to deliver our vision.
Key Drivers for change in End of Life Care
80. National and local strategic drivers prompt a Trust strategy that would reduce
admissions of terminally ill patients into acute hospital beds and result in an increase in
hospice, home and care home deaths. The Working Group has reflected on how this
might be possible and what steps would be needed to achieve this.
Ideal model
81. Our aim is to provide care at the end of life that
 Treats individuals with dignity and respect
 Supports individual choice though an end of life plan that includes preferences on
place of death
 Helps people be free from pain and other symptoms
 Enables people to be in the company of close family and friends
82. The Trust will not be able to deliver this vision without close collaboration with primary,
tertiary, social, independent and voluntary sector colleagues.
83. Patients requiring end of life care enter acute care by three general pathways:
 Patients with previously undiagnosed disease
 Patients with known disease who suffer an acute exacerbation
 Patients with known disease, usually of a chronic nature, who have increasing
dependency
84. The ideal model seeks
 To reduce the admissions to hospital of patients with known disease
 To ensure that patients dying in hospital should be entered onto the Liverpool Care
Pathway (LCP) - a multi-professional document providing an evidence-based
framework for end of life care.
 To bring ideal care to the patient if it is impossible to move the patient to such care
in other, potentially preferred, environments.
85. If patients are already in the community, either at home or in a care home, then ideal
care should be supported through the use of the Gold Standards Framework (GSF),
the Liverpool Care Pathway (LCP) and the Preferred Priorities for Care (PPC)
documentation. The aim of the GSF is to optimise the organisation and quality of care
for patients and their carers in the last year of life. The GSF has been well developed in
the Surrey end of the Trust’s catchment and is now also being rolled out in Sutton and
Version 1.11
Page 26 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
Merton; though progress is yet to be made regarding PPC. (The supporting papers
provide more detail on all of these approaches)
86. A key objective is to anticipate patient admission while they are still at home. This
requires closer partnership working with the Trust’s primary care colleagues. Targeted
case management by community matrons will be also helpful. In cases where the
diagnosis has been well established, an End of Life Care plan needs to be made
explicit and accessible to all appropriate staff, even though such a plan can be modified
in the light of subsequent clinical events. Sharing knowledge and skills across the
Trust/PCT boundary will be the norm working closely with the Specialist Community
Palliative Care Team (SCPCT) in either of the two hospices.
87. Although good case management will obviate the need for admission for some
patients, there will always remain a significant cohort of dying patients who are
admitted to hospital. These will be highly dependent, symptomatic patients who will
require best practice end of life care which may include specialist input from the
Hospital Palliative Care Team (HPCT) and/or commencement on to the LCP. In any
event, the aim should be to facilitate the patient’s end of life plan, including discharge to
a more appropriate location, if desired.
Key Issues to be addressed
88. Again, further multidisciplinary and multi-organisational work is required to integrate
care across sectors to meet the needs of individual patients. This includes embedding
the Liverpool Care Pathway in the work of all relevant inpatient areas within the Trust;
development of education programmes; and greater integration and shared resources
across primary, secondary, tertiary and voluntary/independent sectors (hospices and
care homes). Detailed proposals are laid out in the supporting working papers.
Next Steps and Financial Implications
89. Detailed costing of the items in this EOLC strategy has yet to be made. Darzi assesses
good EOLC as being broadly cost-neutral. However, neutrality taken across the local
health community as a whole may not be neutral for individual providers within it.
90. The South West London Cancer Network has been involved in the Working Group and
has been fully supportive of the idea to develop better EOLC closer to home. It has
also facilitated discussion about the in-reach CNS scheme and is a partner in the joint
proposal to the PCTs. It continues to support the development of LCP, GSF and PPC
roll out.
Women’s and Children’s Services
91. The working group has set out an approach to individualised care which should
strengthen quality and outcomes. This builds on the requirements of National Service
Frameworks and Royal College guidelines to improve risk management and enable
patients to make informed choices about their care.
Key Drivers for Change in Women and Children’s services
92. Key drivers are:
Version 1.11
Page 27 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
 Maternity Services - Royal College guidelines and local commissioning standards
have set minimum targets for consultant presence on labour wards, and are
encouraging the closure of small inpatient paediatric units. Surrey PCT has set a
standard of at least 40 hours of labour ward consultant presence, growing to 60
hours by 2009. This is likely to be mirrored by Sutton and Merton PCT - The
Framework for Action report suggests a minimum of 98 hours presence. Currently
both sites within Trust only have 22 hours of consultant labour ward presence.
 Patient choice is driving increased competition within maternity services. As a Trust
with a number of alternative providers of maternity care in close proximity this is
particularly important.
 The European Working Time Directive (WTD) and requirements for Modernising
Medical Careers (MMC) further exacerbate the pressures on medical staffing. In
addition there are manpower shortages within specialist nursing, which threaten the
quality of care and make it difficult to backfill from this staff group.
 Paediatric Services – Royal College guidelines suggest that WTD and MMC will
drive the concentration of paediatric inpatient services on fewer sites.
93. These drivers present women’s and children’s services with some immediate
challenges, as current services do not meet commissioner and national minimum
standards. The expert panel convened last year as part of the Safety and Sustainability
review concluded that the best way to resolve these deficits would be to concentrate
inpatient maternity and paediatric services on the St Helier site. As described below,
this conclusion had considerable but not universal support from the working group.
There are differences of opinion about which site services should be concentrated on.
The programme of public engagement and strategy work planned with Surrey and
Sutton and Merton PCTs should help clarify these issues and suggest a way forward.
The PCTs will work with the Trust and local stakeholders to understand likely patient
flows if services were concentrated onto one site, and the staffing and financial
implications of this.
Ideal model
94. To offer excellent, patient focussed, evidence based care in the most appropriate
environment.
95. High level ideal pathways for low-risk maternity, high-risk maternity, paediatric
emergency care, paediatric planned care, paediatric chronic disease and disabilities,
and paediatric clinics have been developed (full pathways are laid out in the supporting
working paper A). The ideal pathways seek to promote a high quality care through: Empowering women to make choices – who treats them, where they are treated –
promoting home births
 A systematic approach to risk assessment during pregnancy and birth
 Improve access to paediatric and maternity clinics – timing, fast track options,
location
 Increased information and education for patients
 Increase the level of consultant and midwife input in maternity care
 Increase the level of specialist nursing input in paediatrics
 Opportunities for closer working with primary care – e.g. in paediatric A&E
 Improving the quality of facilities to meet NSF standards and patients expectations
Version 1.11
Page 28 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
96. In addition to describing ideal pathways the groups considered a range of options for
the future configuration of services. While there was strong consensus and support for
the proposed pathways of care, there was majority but not universal support for the
options laid out below.
Maternity Care
97. The group recognised that retaining the status quo would not resolve issues relating to
the provision of consultant labour ward presence without substantial increase in
consultant sessions on both sites. Even if affordable, these increased hours would not
result in increased births so the productive efficiency of the units would fall and this
solution was likely to be unaffordable.
98. Notwithstanding this, there was significant body of clinical support for consultant-led
deliveries and neonatal services to be concentrated on one site. For the majority of
those supporting concentration, St Helier was the preferred site to ensure collocation
with other acute services.
Children’s services
99. There was strong support for improving the quality of the services and environment to
meet the requirements of the National Service Framework. However, there were
divided views on the need to consolidate inpatient services on a single site. Again, it
was recognised that work being done elsewhere is seeking to develop a preferred
clinical option for the future configuration of children’s services and that this would be
subject of formal public consultation if significant service change is proposed.
Outpatient Care
100. Children’s services are already more community based and integrated with primary
care services than adult services are, especially around Epsom; this was seen as an
ongoing evolutionary process that was set to continue. However, there are
opportunities for greater integration and improved communication through the use of
telephone and email advice. Current funding arrangements are a constraint on
implementing change and negotiations between the Trust and the PCTs to address this
issue would be welcomed.
Next Steps and Financial Implications
101. Surrey PCT will lead a piece of work to explore with the Trust and Sutton and
Merton PCT how we can respond to Surrey PCT’s commissioning intentions, and the
emerging framework for maternity services in London, in order to deliver sustainable
maternity and paediatric services across our two sites. The programme will include
significant public engagement in east Surrey and Sutton and Merton. The programme
is expected to begin in late autumn 2007 with the case for change delivered by spring
2008. Any resultant consultation process would then take place summer 2008.
Timelines for the delivery of projects and benefits will be set out in the Case for Change
that will be developed following the engagement process.
102. Expected outcomes from this work include:
 Clinically and financially sustainable women’s and children’s services across the
Trust’s two principal sites
 Accessible services for patients across the Trust’s catchment population
Version 1.11
Page 29 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
 Compliance with Surrey PCT and Sutton and Merton PCT commissioning intentions
 An open and transparent engagement process based on national best practice
 Public involvement and participation in the process of designing the services and
pathways
Conclusion
103. This report sets out our emerging clinical vision for how services in the Trust should
develop over the next 10 years. It is a vision that has been developed by our clinical
workforce with valuable contributions from patients, community providers and our
commissioners.
104. Much of what we describe can be acted upon now and deliver immediate benefits
for patients. Many of the suggestions require changes in the way people work rather
than additional resources. For example, developing job plans to support clinical staff
working across both sites. Many suggestions can also be incorporated into the work
being undertaken as part of the recovery plan. However there are a number of
recommendations that will require a business case before they can proceed. Support
will be given to the relevant service areas to enable this to happen.
105. In all that we do we need to recognise a rapidly changing environment. A
significant part of our challenge is to build flexibility into our services, workforce and
facilities.
So how does it all add up?
Delivering the vision
106. We will forge strong partnerships with local primary and tertiary care providers.
This will strengthen our position as secondary care provider of choice for the
populations of south Merton, Sutton, Epsom and the surrounding areas.
107. A question that many of our staff and stakeholders will be asking – is how does this
all add up? What does it mean for each of our acute hospital sites? The diagram below
sets out a tiered approach: an approach in which the majority of acute medical care
can be retained on the Epsom site.
Epsom
A&E & Primary care led
urgent Care
Acute Medicine – Defined
No acute surgery or trauma
Elective Surgery - Majority
HDU flex to ITU
Obstetrics ?=>Low risk or
Ambulatory*
Paediatrics ?=> assessment*
24/7 Diagnostics
Outpatients with primary care
input
Version 1.11
Page 30 of 41
St Helier
A&E & Primary care led
urgent Care
Acute Medicine
Acute surgery and trauma
Elective Surgery – some
complex
HDU & ITU
Obstetrics (=> 98 hours
cover)*
Paediatrics*
24/7 Diagnostics
Outpatients with primary
care 2008
24th January
input
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
*Subject to consultation
108. This is a model which requires significant further work, and no changes to existing
services are anticipated in advance of public engagement and consultation. The
purpose is to help people visualise the future as a contribution to the wide strategic
debate.
109. Comments on this draft strategy
[email protected]
to
be
submitted
to
Keith
Hider.
NEXT STEPS
110.
This paper will be presented to the Trust Board on 7 th December 2007.
111. As the document makes clear it is the beginning of a strategic conversation, not the
end.
112. Our first priority is to understand the affordability of the models, and viability in
workforce terms. This is a particular issue for the acute medical model and we will
need further clinical input to this appraisal. We will need to look at a high level at the
estates implications and any immediate barriers to implementation of the models.
113. We will also need to conduct a financial appraisal on a number of issues which
have not been explored in depth within the clinical strategy but are important for us to
resolve as a trust as we move forward:
 Emergency Surgery – understanding the implications of the S2 changes and
exploring the opportunity and financial implications of expanding out-of-hours
surgery to accommodate work from neighbouring trusts
 Local care – understanding clinical, logistical and economic issues in relation to
devolving activity to local care centres
 Renal services – implications of Surrey and South West London Collaborative
commissioning intentions
 Sutton Hospital – determining which services can remain in local care settings and
where they should be located; and which services need to be configured across the
Epsom and St Helier hospital sites
 Day Surgery and Ophthalmology – identifying the optimal configuration of services
for efficiency and effectiveness across our hospital sites
114. We wish to engage clinicians and staff at this stage to help us adapt the strategy to
ensure our clinical ambitions are both affordable and sustainable. Clinical input will be
required to work up new staffing models and provide more detail to understand the
operational implications.
115. We will be developing a staff engagement programme to give all staff the
opportunity to learn more about the proposals and get involved in taking forward the
next phase of planning activities. Details are being worked up but will include a variety
of direct and indirect communications methods to try to ensure the widest possible
coverage. This will include open briefing sessions, across all sites and including events
Version 1.11
Page 31 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
at unsocial hours and weekends; poster and leaflet displays with feedback
mechanisms; and use of the Trust intranet as a repository of working documents.
116. We also plan to use the work to help frame next years business plans and will be
engaging with each Division and the PCTs to identify “quick wins” and their proposed
approach to business case development in the areas for which they are leading. Whilst
the affordability of the main elements has yet to be determined, there are a number of
issues that could be taken forward during the coming year and should be identified in
the business plan and taken forward in SLA negotiations.
117. The following are proposed:
 Supporting our local PCTs’ aspirations to develop the “single front door” to A&E with
a primary care led urgent care service within it. Work will commence with both
PCTs to progress this.
 Increasing senior medical input to the decision making process around emergency
patient admissions. Urgent action is required on the Epsom site which has a deficit
in middle grade cover. This is an area which would benefit enormously from senior
clinical staff working across both sites.
 Working with our PCTs to address deficits in current specialist nursing support and
developing in-reach services in order to maintain appropriate standards of End of
Life Care.
 Working with Practice Based Commissioners to find economically viable ways of
devolving of phlebotomy and some other routine diagnostics into community
settings.
 Promoting greater integration of primary care and children’s services, e.g. primary
care input to children’s A&E (to be taken forward as part of the wider Women’s and
Children’s review).
 Fostering networks development between acute trusts and between primary and
secondary care. It is proposed that one or two specialties could be targeted in the
first instance. For example, Sutton and Merton PCT have suggested neurology
services, building on the good practice example of the way in which Epsom Hospital
consultants link to community based services in Surrey.
118. Finally we plan to use this and the subsequent work to frame our responses to the
London consultation on a Framework for Action, and the strategic development work
we are undertaking with our local PCTs.
Version 1.11
Page 32 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
APPENDIX A - Details of working group membership and
wider engagement
The following either attended meetings and / or were included in circulation of meeting
documents.
Steering Group
Lindy Steven (Chair)
Sam Jones
Candace Imison
Steve Lennox
Patricia Wright
Jim Stephenson
Hervey Wilcox
Norman McWhinney
(Chair of W&C)
Pieter Le Roux (Chair of
AC)
Oliver Duke (Chair of PC)
Mashkur Khan (Chair of
CDM)
Andrew Hoy (Chair of
EoLC)
Guan Lim
Wendy Brooks
Jas Weir
Jill King
Ruth Milton
Martyn Wake
Kevin O'Brien/Mike Smith
Jo Pritchard/Tricia
McGregor
Keith Hider
Medical Director
Chief Executive
Director of Strategy
Director of Nursing
Director of Clinical
Operations
Director of Clinical
Services Division
Director of Clinical
Networks Division
Medical Lead for Obs &
Gynae
Consultant Urologist
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Consultant
Rheumatologist
Consultant of Medical &
Emergency Services
Medical Lead for
Palliative Medicine
Consultant
Gastroenterologist
Senior Stroke Nurse
PPI Forum
Programme Director for
Fit for Future Programme
Director of Public Health
Medical Director
Unison Representative
Joint Managing Directors
Epsom/St Helier Univ NHS Trust
Head of Strategy/
secretariat
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Surrey PCT
Surrey PCT
Sutton & Merton PCT
Epsom/St Helier Univ NHS Trust
Central Surrey Health
Women and Children's Working Group
Norman McWhinney
Chair)
Ruth Charlton
Version 1.11
Medical Lead for Obs &
Gynae
Director of Family Care
Division
Page 33 of 41
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Richard Chavasse
Paula Sneath
Maria Garcia
Naglaa Salem
Carolyn Croucher
Vijayasri Kakumani
Mary Warren
Kirsten Younger
Sue Knowles
Ginny Hancock
Selvi Pathma
Ruth Shepherd
Teresa Manders
Pauline Fonteriz
Debbie Frodsham
Alison Ryley
Maddie Quiney
Lorna Bramwells
Catherine Swanson
Tracy Smith
Tina Woodford
Toni Johnston
Geraldine Cotter
Jeanette Hennessy
Carol Hood
Maureen Millard
Mary Raw
Jane Doran
Nicola Young/Jill Keep
Margaret John
Jackie Levy
Nick Gorvett
Charlotte Gawne
Version 1.11
Medical Lead for
Children’s Services
Consultant Paediatrician
Consultant Paediatrician
Consultant Paediatrician
Consultant Obs & Gynae
Consultant Obs & Gynae
Consultant Radiologist
Consultant Radiologist
Consultant Haematologist
Supt Paediatric
Physiotherapist
Consultant Anaesthetist
Consultant Neonatologist
Head of Midwifery
Professional Nurse
Advisor/Lead nurse,
Paediatrics
General Manager
Emergency Care
Senior Nurse Paediatric
Home Care Team QMHC
Community Midwife
Senior Nurse - Acute
Paediatrics
Senior Nurse
Neonatology
Lead Nurse A&E
Lead Midwife St Helier
Lead Midwife Epsom
Senior Sister Neonatal
Unit
Delivery Suite
Coordinator
Staff Nurse Casey Ward
Senior Sister Casey Ward
Senior Sister Ebbisham
Ward
Senior Nurse Paediatric
Home Care Team - EGH
Unison, RCM/Women's
Health
Pharmacy Dispensing
Manager
Service Manager Obs &
Gynae
Director of Corporate
Infrastructure
Director of
Page 34 of 41
Clinical Strategy
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Patricia Wright
Candace Imison
Madeline Boissiere
Susanne Senhenn
Tim Richardson
Selina Master
Emma Harewood
Sally Bonynge
Sue Oakenfull
Heather Lings
Ruth Clancy
Nicola Waldham
Paul Alford
Liz Sherlock
Ann Howers
Keith Hider
Communications
Director of Clinical
Operations
Director of Strategy
PPI Forum
GP
GP
Director Clinical Dental
Service
Dietetic Services
Manager
Operational Manager
Head of Speech &
Language Therapy
Services
GP
GP
GP
GP
Women’s Health Nurse
Specialist - S&M PCT
Children’s Health
Services Manager - S&M
PCT
Head of Strategy/
secretariat
Clinical Strategy
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Surrey PCT
Surrey PCT
Surrey PCT
Central Surrey Health
Central Surrey Health
Central Surrey Health
Sutton & Merton PCT
Sutton & Merton PCT
Sutton & Merton PCT
Sutton & Merton PCT
Sutton & Merton PCT
Sutton & Merton PCT
Epsom/St Helier Univ NHS Trust
Planned Care Working
Group
Pieter Le Roux (Chair)
Chris Harland
Simon Moodie
Peter Fison
Paul Hart
James Clark
John Foran
Neil Citron
Paul Toomey
Gail Darlington
David Male
Lydia Jones
Version 1.11
Consultant Urologist
Consultant Dermatologist
Consultant
Gastroenterologist
Consultant
Ophthalmologist
Consultant Neurologist
Consultant Orthopaedic
Surgeon
Consultant Cardiologist
Consultant Orthopaedic
Surgeon
Consultant General
Surgery
Consultant
Rheumatologist
Consultant Anaesthetist
Consultant Cancer
Services
Page 35 of 41
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Tiz North
Chris George
Andy Keane
Lynn Bryan
Lynn Ring
Sharon Blain
Pippa Hart
Martin Hesketh
Anne Davies
Peter Cook
Jon Sargeant
Peter Gill
Patricia Wright
Candace Imison
Sue Hallam
Sylvia Aslangul
Peter Stott
Annette Champion
Martyn Wake
Fiona White
Denver Greehalgh
Philippa Marshall
Sandy Keen
Keith Hider
Clinical Strategy
Consultant Diagnostic
Imaging
Consultant Radiologist
Consultant Radiologist
Lead Nurse Post Acute
Care
Head of Nursing
Ophthalmology
Contract Administrator
Pre Op Assessment
Professional Nurse
Advisor Surgical Services
Lead Nurse/ODP
Chief Pharmacist
Divisional Manager for
Clinical Networks
Director of Finance
Director of Information
Services
Director of Clinical
Operations
Director of Strategy
Unison/RCN & Theatres
PPI Forum
GP
OT Manager
Medical Director
Consultant Nurse
Assistant Director
Provider Services Merton
Acute & Neuro
Rehabilitation Manager Sutton
Asst Director of Provider
Services
Head of Strategy/
secretariat
Epsom/St Helier Univ NHS Trust
Consultant
Rheumatologist
Consultant Physician
Consultant Physician
Consultant Anaesthetist
Consultant Surgical
Services
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Surrey PCT
Central Surrey Health
Sutton & Merton PCT
Sutton & Merton PCT
Sutton & Merton PCT
Sutton & Merton PCT
Sutton & Merton PCT
Epsom/St Helier Univ NHS Trust
Acute Care Working
Group
Oliver Duke (chair)
Guan Lim
Ajay Bhalla
Martin Stockwell
Paul Thomas
Version 1.11
Page 36 of 41
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Olusola Odemuyiwa
Dilip Shah
Sri Srinivas
Lindsey Stevens
Tiz North
Chris George
Marta Lapsley
Fiona Ashworth
Lindy Steven
Chris Jones
Jonathan Kwan
Candace Imison
Patricia Wright
Hilary Bennett
Pippa Hart
Beccy Ellis
Tracy Smith
Tanya Fuller
Helen Reed
Wendy Brooks
Anne Davies
David Heal
Tim Richardson
Nav Chana
Simon Elliott
Tahir Toosy
Philippa Marshall
Denver Greenhalgh
Jane Carey-Harris
Val Gregory
Keith Hider
Consultant Cardiologist
Consultant Medical &
Elderly
Consultant A&E
Clinical Director A&E
Medical Lead Diagnostic
Imaging
Consultant Radiologist
Consultant Pathologist
Divisional Manager
Emerg & Medical
Services
Medical Director
Divisional Director
Surgical Services
Medical Lead Renal
Services
Director of Strategy
Director of Clinical
Operations
Sister on CAU
Prof Nurse Advisor for
Critical Care/ Surgical
Services
Lead Nurse ITU HDU
Lead Nurse A&E
Sister on B6
Senior Physiotherapist
Stroke Nurse Consultant
Head of Pharmacy
PPI Forum
GP
GP
GP
GP/PBC
Acute & Neuro
Rehabilitation Manager Sutton
Asst Director Provider
Services - Merton
Service Improvement
Manager
Sister/Unison rep
Head of
Strategy/secretariat
Clinical Strategy
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Surrey PCT
SMPCT
SMPCT
SMPCT
SMPCT
SMPCT
SMPCT
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Chronic Disease Management Working Group
Mashkur Kahn (chair)
Version 1.11
Consultant Emergency &
Page 37 of 41
Epsom/St Helier Univ NHS Trust
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Andrew Rodin
David Makanjuola
Shakil Rahman
Jane Mercieca
Michael Ward
Sara Blakey
Sara Youngman
Helen Parnell
Anne Lowson
Jill Stevens
Hervey Wilcox
Candace Imison
Helen Lewis
John Tugwell
Sue Mitchell
Martyn Wake
Jackie Tapping
Denver Greenhalgh
Sandy Keene
Jane Carey-Harris
Julie Wilson
Julie Davey
Keith Hider
Medical Services
Consultant Diabetes
Consultant Renal
Nephrology
Consultant General
Medicine
Consultant Haematologist
Consultant Geriatrics
Prof Nurse Advisor
Lead Nurse Renal
Respiratory Clinical
Nurse Specialist
Pharmacist
Pharmacist
Divisional Director
Pathology
Director of Strategy
PPI Forum
PPI Forum
GP
GP/Medical Director
Nurse
Asst Director Provider
Services - Merton
Assistant Director of
Provider Services
Service Improvement
Manager
Planning &
Commissioning Officer
Specialist Nurse
Head of
Strategy/secretariat
Clinical Strategy
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Surrey PCT
SMPCT
SMPCT
SMPCT
SMPCT
SMPCT
Sutton Social Services
Central Surrey Health
Epsom/St Helier Univ NHS Trust
End of Life Care
Working Group
Andrew Hoy (chair)
Martine Meyer
David Spratt
Sue Clelland
Louise Costella
Julia Lowes
Jackie McNicholas
Version 1.11
Medical Lead Palliative
Medicine
Consultant Cancer
Services
Cellular Pathologist
Specialist Nurse Palliative
Care
Specialist Nurse Palliative
Care
MacMillan Nurse,
Palliative Care
Pre Dialysis Nurse Renal
Page 38 of 41
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Dawn Brewer
Sheena Woodward
Candace Imison
Alison Hill
Maureen McGinn
Val Crooks
Margaret Golding
Jill Stevens
Shelley Dolan
Sue Dew
Roy Prytherch
Amanda Free
Ash Mirza
Gillian Tame
Karen Masetti
Jane Carey-Harris
Dawn Bliss
Linda Henson
Eva Garland
Keith Hider
Version 1.11
Specialist Nurse
Haematology
MacMillan Nurse,
Palliative Care
Director of Strategy
Network Nurse
Project Coordinator
End of Life Care facilitator
Sister from A6
Pharmacist
Chief Nurse
Interim Director of HR
PPI Forum
GP
GP
Nurse
Team Coordinator
Service Improvement
Manager
Senior Sister/Ward
Manager/Unison rep
Educational Training
Director of Clinical
Services
Head of
Strategy/secretariat
Page 39 of 41
Clinical Strategy
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
SMPCT
SMPCT
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Epsom/St Helier Univ NHS Trust
Royal Marsden Hospital
Epsom/St Helier Univ NHS Trust
Surrey PCT
SMPCT
SMPCT
Central Surrey Health
SMPCT
Epsom/St Helier Univ NHS Trust
St Raphaels Hospice
Princess Alice Hospice
Epsom/St Helier Univ NHS Trust
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
APPENDIX B - Epsom and St Helier Trust, Facts and Figures
Clinical Activity
Most of the Trust’s services are commissioned by Sutton and Merton PCT and Surrey
PCT. Between them, these PCTs account for 54% and 37% of patient admissions
respectively. In general, the majority of Surrey PCT activity takes place at Epsom and the
majority of Sutton and Merton PCT activity takes place at St Helier.
Set out below are some key facts and figures about the Trust based on 2006/07 data.
Epsom
Outpatient attendances
New
FU
A&E attendances
Admissions
Non-elective
Elective Inpatient
Daycase
Maternity Deliveries
Beds (October 2007)
A&E
Adult
CCU
Children
Critical Care
Maternity
Neonatal
Renal
Total
Theatres
St Helier
Other
Total
31757
107698
50275
61574
177317
74308
26278
75581
6175
119609
360596
130758
16467
2740
7242
2080
29748
3413
9357
2795
0
3592
8396
0
46215
9745
24995
4875
4
182
14
16
7
35
8
4
308
14
18
11
58
20
48
481
10
3
8
490
28
34
18
93
28
48
747
20
266
7
Financial and service performance
The Trust reported a £5.543m deficit for 2006/07 and is currently in turnaround in order to
achieve financial balance by the end of 2008/09. A major recovery programme is
underway which is driving improvements in efficiency and effectiveness, and has many of
the same ambitions that we lay out in this strategy.
The Trust employs 3603 whole time equivalent staff, of which 2362 (66%) are employed in
clinical roles (September 2007).
Neighbouring providers
St Helier has a number of other acute providers in close proximity: St George’s Hospital,
Tooting; Kingston Hospital; Mayday Hospital in Croydon. Epsom’s nearest neighbour’s
Version 1.11
Page 40 of 41
24th January 2008
Epsom and St Helier University Hospitals
NHS Trust
Clinical Strategy
(other than St Helier) are East Surrey Hospital (Surrey and Sussex Healthcare) in Redhill;
the Royal Surrey County Hospital in Guildford and St Peter’s Hospital, Chertsey.
Kingston
Mayday
RSCH
St George's
St Helier
St Peter's
Road distances* (miles)
East Surrey
Epsom
East Surrey
Travel time* (minutes)
30
52
42
41
51
41
32
32
34
31
29
21
22
39
52
26
28
42
64
19
23
56
62
55
25
17
52
Epsom
16.6
Kingston
21.3
10.1
Mayday
14.6
11.0
11.3
RSCH
27.6
19.4
25.1
30.7
St George's
19.0
9.8
6.7
5.8
26.1
St Helier
15.2
6.9
7.4
6.3
26.7
4.6
St Peter's
23.8
15.5
15.8
26.8
25.0
25.1
42
22.2
*Source: AA Route Planner – www.theaa.com
In addition to these acute sites, there are a number of local community and independent
developments that potentially impact on Trust services. These include:
 Cobham Cottage Hospital – ISTC provision for daycase and outpatient services.
Planned daycase volume c.10,000 FCEs p.a.
 Sutton and Merton PCT Local Care Centre developments – plans include centres at
the Nelson Hospital, Wilson Hospital, Shotfield in Wallington and on the St Helier
site. Local Care Centres are planned to take the bulk of Sutton and Merton
ambulatory care services (outpatients, daycases, rehabilitation and diagnostics) as
well as providing accommodation for some GP practices and other primary care
services.
Sites and estate
Of the three sites operated by the Trust, St Helier Hospital is the largest with 53,000m 2 of
floor space. The fabric of this pre-war building is poor. Backlog maintenance is estimated
at £13.6m. Epsom General Hospital has 39,500m 2 of floor space and the majority of
buildings date from after 1970. Several buildings were built during the 1990s, notably the
Bradbury Wing, the Maternity Unit and the shell of the Denbies Wing, which now
accommodates A&E (opened 2001) and SWLEOC (opened 2004). Backlog maintenance
on the older part of the site is estimated at £6.4m6. Sutton Hospital has 20,500m2 of floor
space. Most of the buildings date from the early 20th century and some buildings are
closed. None of the buildings provide accommodation to 21 st century standards. Backlog
maintenance is estimated at £3.6m4. A longstanding strategic priority has been the
renewal of the Trust’s estate.
6 2007/7 ERIC return
Version 1.11
Page 41 of 41
24th January 2008