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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