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Agenda Item: 04 Enclosure: CKWCB/13/04 DATE OF MEETING:

Category of Paper Tick( )

10 January 2013 Paper Title:

Decision and Approval


Position statement

Responsible Director:


Jo Webster


Paper Author:

FOI Status: Open

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Caroline Griffiths Lee Beresford This paper highlights the commissioning case for change; and details the process of design, the configuration options, highlights local responses and describes the approach to stakeholder and public consultation for the Mid Yorkshire Clinical Services Strategy outline business case.

Executive Summary:

A summary of the outline business case for the Mid Yorkshire Hospitals Clinical Service Strategy is shown in appendix. Financial and other resource implications and key risks and actions are addressed within the summary of the outline business case. A presentation on key aspects of the commissioning case for change and outline business case will be provided at the Public Board meeting, highlighting future benefits and further work which will be undertaken in the Transformation Programme. Outcome of Equality Impact Assessment:

Impact assessment is addressed within the outline business case. 1

Sub Group/Committee:

North Kirklees and Wakefield CCEs

Recommendation (s):

Board members are asked to support the outline business case and agree to proceed through the Service Change Assurance Process to public consultation.


1. Purpose This paper describes the commissioning case for change and the development of the Clinical Service Strategy for acute hospital services which is required to support the overall Transformation Programme. 2. Background The Health and Social Care Transformation Board is established to ensure that key partners are working together to deliver local service transformation and this paper highlights six key reasons for making significant changes in the way healthcare is delivered in Mid Yorkshire:      

Reason one: the need to adopt new models of care and best practice which can deliver better outcomes for patients and deliver safe and excellent quality services; Reason two: the need to improve the health of people in Wakefield and North Kirklees and ensure healthcare services are meeting public expectations; Reason three: the population is rising and ageing leading to greater and different demands on health services; Reason four: hospital is not always the answer; more care can be delivered in community settings than ever before and patients benefit from care closer to home; Reason five: there are workforce challenges which currently prevent delivery of the best quality care and optimal patient outcomes; and Reason six: the need to make best use of taxpayers’ money.

3. Commissioning case for local transformational change Our populations are growing and our people are living longer. However, the impacts of unhealthy lifestyle choices and the continuing economic crisis are leaving their marks upon both districts and are contributing to the health problems being faced by our communities. Areas of North Kirklees and the Wakefield district are significantly deprived and there are wide health and economic gaps between communities. A significant number of local people face poorer health, education, housing and employment opportunities. Finding solutions to these complex local challenges will depend in significant part upon the development and maintenance of excellent partnership working. The strategic intentions of both NHS Wakefield and NHS North Kirklees CCGs are well described. Our respective Joint Health and Wellbeing Strategies provide the common framework for individual agencies to develop commissioning and delivery plans which will together meet the needs of all our communities and encapsulate the joint principles by which all partners agree to operate. Increased partnership working will enable better outcomes for local people that are delivered in more efficient ways. We are both committed to achieving a fundamental shift in local thinking from an NHS that traditionally addresses ill-health first and then promotes wellbeing, to one that promotes health and wellbeing and addresses ill-health to the highest possible standard. We believe that this can be seen to offer three main benefits: 

better outcomes for service users and patients (person-centred, recognising that health and social care outcomes are interdependent); 3

 

making limited resources go further (leading to better system efficiency through better co-ordination of service commissioning); and Improving people’s experience of health, care and support (facilitating the social integration of our more vulnerable groups through better access to flexible and inclusive community services).

Local people will as a result:       

feel like they are dealing with one local organisation; have access to accurate information which will enable them to make informed choices and take more responsibility for their health and wellbeing; be able to get the right care and treatment quickly without having to deal with lots of different people; have to provide personal information only once that will be shared securely with other organisations involved in the person’s care; experience safe and effective care and treatment delivered by well-trained teams, at home or near to home or at another place that is convenient for them; always experience care that is coordinated and their family and carers are kept informed; be supported to be as independent of public services as possible through a local care system that promotes prevention, self care and empowers supportive communities.

The Joint Strategic Needs Assessment (JSNA) provides a summary of the current and future health and wellbeing needs of people in the Kirklees and Wakefield districts. It is a key planning and commissioning tool, covering a breadth of health and social needs and wider factors affecting the wellbeing of our communities. 4. The Outline Business Case for the Mid Yorkshire Clinical Services Strategy The Outline Business Case (OBC) for the Mid Yorkshire Clinical Service Strategy was developed in response to the North Kirklees and Wakefield Commissioning Strategy ‘Meeting the Challenge’. The commissioning strategy sets out the local context for fundamental changes in the way care is provided ‘Closer to Home’. Working in collaboration with other agencies involved in delivering the Health and Wellbeing strategies for both local authorities, the Clinical Commissioning Groups (CCGs) will be driving service changes through investment and disinvestment according to local needs and priorities. The Outline Business Case for acute hospital services focuses on improving acute care pathways which will respond to future demand not through hospital beds but through better coordination of secondary care, primary care, community and local authority services. The future emphasis will be on both integrated commissioning and integrated delivery reflecting patient needs and choice. The Executive Summary for the OBC is attached in the appendices. The case describes a future configuration of acute services based on the key principles outlined in the commissioning strategy:  Reducing avoidable admissions;  Improving pathways and redesigning emergency ambulatory care;  Reducing hospital stay by improving discharge processes. 4

The future acute service configuration set out in the OBC has been developed to deliver high quality and safe services in the future reflecting a wide range of local and national drivers for change. As services are developed locally and nationally the Trust aims to be one of the best performing Trusts by:  Driving improvement in service quality, safety and performance delivering better outcomes for patients and quality services;  Promoting better ways of working between community and hospital services so that people are treated in the best place for them by staff who have the most appropriate skills  Ensuring that people’s experience in using our services is the best it can be  Improving the health of people in Wakefield and North Kirklees and meeting public expectations;  Responding to an ageing population which result in greater and different demands on health services;  Recognising hospital is not always the answer; and that more care can be delivered in community settings which is better for patients  Developing a workforce challenges which can provide the best quality care and optimal patient outcomes; and  Make the best use of taxpayers’ money. The draft OBC sets out the local and national case for change in relation to the Trust’s services including the following issues:  The year on year increases in demand for emergency care, placing pressure on the Trust’s services as well as affecting the provision of elective services;  The future availability of medical staff, particularly in the junior and middle grades – the Royal Colleges and Deanery have also notified the Trust of future reductions in trainee doctors;  Recommendations resulting from the National Clinical Advisory Team (NCAT) following a review of the Trust’s services carried out in 2010. In addition the Trust had a review undertaken on its women’s services in 2011 by an expert team from Southampton University Hospital NHS Trust. The reviews recommended the consolidation of services on one site, examples being acute surgery, paediatrics and obstetrics.  NCAT recommendations regarding the split between elective and non-elective services would support the Trust’s ability to meet the 18 week targets, cancelled operations not admitted within 28 days, elective length of stay targets and MRSA infection rates.  Future commissioning requirements for specialist services which will result in wider reconfiguration of services across many providers  Increasing regulatory requirements particularly in relation to CQC standards and quality governance  Greater focus on 24/7 consultant delivered services for quality and efficiency reasons  The need to achieve greater economies of scale and efficiency in delivery pathways especially for subspecialist services


The draft OBC describes 2 future options for the clinical service strategy as summarised below; Option 1

Option 2

 Emergency Departments, ICU and HDU facilities at Pinderfields (PGH) and Dewsbury.  Consolidation of paediatric inpatients and non-elective and elective general and colorectal surgery in PGH.  Dewsbury becomes a midwifery led Maternity Unit, Clinical Decision Unit for acute medicine, centre for neuro rehabilitation, elective surgical and Day Case unit  Out of hours ITU/support services required on Dewsbury site for some non-elective care.

 Pinderfields becomes An Emergency Care Centre including acute medicine and Pontefract and Dewsbury become emergency care units in an integrated emergency care network.  Pontefract and Dewsbury become centres for elective surgery, outpatients and diagnostics and sub acute services.  Dewsbury becomes midwifery led Maternity Units, Clinical Decision Unit for acute medicine, centre for neuro-rehabilitation as in Option 1.  Consolidation of all non-elective activity at Pinderfields together with ICU and HDU facilities.

The option appraisal process undertaken by the Trust and key stakeholders in July concluded that Option 2, was the preferred option as this provides both a clinically and financially sustainable solution Key features of the preferred option are:  Separating emergency and elective care to improve quality and outcomes;  A number of assumptions have been used in developing the capacity model based on quality and efficiency;  The development of Dewsbury Hospital as the Mid Yorkshire centre of excellence for rehabilitation;  Realignment of capacity is required at Pinderfields to ensure the is a permanent and flexible response to future trends;  Estate and capital requirements for both Dewsbury and Pinderfields sites  Workforce implications of changing capacity and service configuration across the three hospital sites. The Board is asked to note the changes to acute services have been developed in the context of also developing high quality integrated primary and community services which are critical to reducing reliance on hospital care and therefore enabling the changes required for Option 2. The service models required to support the future hospital configuration are being developed by clinical leaders across primary and secondary care to reflect best practice outcomes for patient care. Further development of the clinical models will reflect public and patient involvement and feedback through the public consultation process. In addition external assurance will be provided by the National Clinical Advisory Team (January 2013) and Department of Health Gateway process for reviewing service change (also in January 2013).


This OBC reflects the changes in acute service provision in the future and will be complemented by further business cases for care closer to home as described in the developing CCGs commissioning plans. As such this OBC describes one aspect of service change and development which will be supported by essential changes in primary and community services including social care. The OBC was reviewed in detail by the Mid Yorkshire Hospitals NHS Trust Board in November 2012 which approved the proposal. The Board recommended that North Kirklees and Wakefield CCGs and the NKW Cluster should undertake Public Consultation on the proposals in March 2013 supported by further development of the primary and community service changes in care outside hospital. Both CCGs are fully supportive of the proposals in the OBC and are committed to working with the Trust on the new models of care that will be required to support the strategy. The OBC will be developed into a full business case which will include greater detail of the new models of care, workforce plans and estate requirements. 5. Consultation and pre-consultation Throughout the process of developing these proposals, we have set out to work as closely as possible with all our stakeholders to consider how we can best meet the challenges facing us and actively involve them in developing solutions. Following clinical review, five initial options were developed and communicated widely to patients and the public: we ran a series of events and activities in autumn 2011 to get their views and feedback. This was particularly aimed at the people that were likely to be most affected by any of the potential changes being discussed, including A&E, children’s inpatient surgery, neurology and neurological-rehabilitation, cardiology, maternity, orthopaedics and spinal injuries. Once the scale of the financial challenge emerged and it was clear a more radical approach would be required, clinicians carried out further work to consider new options. This included a large multi-stakeholder event in June, which was attended by patient and public representatives, to inform the development of new options and agree the non-financial criteria against which these should be assessed. This was followed by a formal option appraisal event in July to assess the new options against the agreed criteria. A range of stakeholders were involved in this, including hospital and community clinicians, GPs and patient representatives. This exercise was repeated and validated through further option appraisal events with the Kirklees and Wakefield LINKs and the patient advisory group, to ensure patient and public views were well-represented. Following the identification of the options for consideration, we met with a wide range of stakeholders to raise awareness and understanding of the options, and discuss the reasons for change and the benefits and challenges associated with the options. This included both large public meetings and smaller special interest and focus groups, including: • • •

Area committee meetings and area forums/networks LINk public meetings Meetings with local councillors 7

• • • • •

GP practice Patient Reference Groups Disabled People’s Partnership Board Interfaith Group Media – regular briefings, interviews, articles A range of health related interest/support groups

A full list of the groups is available on the website: To support this work, we established a patient and public advisory group to advise on arrangements for engagement and monitor engagement activity, ensuring this appropriately reflects the diversity of the populations. We also set up the ‘Your Health, Your Say’ initiative to build a network of people interested in being involved in health services, both around these changes and going forward. Opportunities to join this have been promoted at every meeting we have attended and at a wide range of community events across the whole area. In the months immediately prior to the proposed consultation, we continued to engage with all stakeholders to maintain an ongoing dialogue over the possible changes, the benefits and challenges, and to highlight the emergence of a preferred option. The aim of this work was to understand any concerns about the options being discussed and identify possible solutions to these. To support this, we ran an awareness-raising campaign to try to ensure as many people as possible were aware of the need for change, the possible changes being discussed and how to get involved. This included advertising, direct mail and publicity through print, broadcast and social media. To ensure we heard from as wide a range of people as possible, we carried out a survey, based on random selection, of a demographically representative profile of both the North Kirklees and Wakefield District areas. From this, people were also recruited to attend a deliberative event where the case for change was set out and discussions held on the key areas: A&E, maternity, children’s services and care closer to home. The consultation will build on the continuous process of engagement we have tried to ensure throughout this work, and based on the ways people told us worked well. We will also take account of evaluation work currently being carried out to assess how effective different communications channels have been during the awareness raising campaign. This extensive pre-consultation exercise has adequately prepared the OBC to proceed to SCAP and then to public consultation. A number of key stakeholders have been approached. These are:         

Yorkshire Ambulance Service NHS Trust NHS Rotherham NHS Barnsley South West Yorkshire Partnership Foundation Trust Locala Community Partnership CIC Spectrum CIC Wakefield District Council Kirklees Council Leeds West CCG 8

       

NHS Leeds NHS Bradford NHS Calderdale NHS East Riding Leeds Teaching Hospitals NHS Trust Sheffield Teaching Hospitals NHS Foundation Trust Barnsley Hospital NHS Foundation Trust Trust Development Authority

Following the CKW Cluster Board decision on the recommendations outlined in this paper the following milestones will be agreed with the Mid Yorkshire NHS Board and Transformation Board. Key event


OBC Completed OBC to CKW Cluster Board Service Change Assurance Process (SCAP) Preparation of consultation documents Completion of care pathways and workforce plan Public Consultation on proposed Clinical Services Strategy Consultation analysis complete Update of Strategic and Economic Cases complete Completion of Financial Case (affordability analysis) Completion of FBC

November 2012 January 2012 January and February 2013 December 2012 – February 2013 October 2012 – April 2013 March – May 2013 June 2013 June 2013 June 2013 July 2013

6. Recommendation Board members are asked to support the outline business case and agree to proceed through the Service Change Assurance Process to public consultation.