National Clinical Advisory Team – NCAT Chair: Dr Chris Clough King’s College Hospital Denmark Hill London SE5 9RS
NCAT review To:
Mid Yorkshire Hospitals NHS Trust Service Reconfiguration
28 June 2010
Administrator Judy Grimshaw Tel: 020 3299 5172 Email: Judy.firstname.lastname@example.org
NCAT Visitors Chris Clough Margaret Gibson Martin Shalley Simon Wood
Chair, NCAT Consultant Neurologist Programme Manager, Intermediate Care Services Sheffield Retired Emergency Medicine Consultant, Former President British Association of Emergency Medicine Programme Director, QIPP & Towards the best, together NHS East of England
Introduction A National Clinical Advisory Team (NCAT) visit was requested by NHS Yorkshire & the Humber at the behest of the then Secretary of State for Health Andy Burnham. This followed correspondence from Yvette Cooper MP (Pontefract and Castleford), Mary Creagh MP (Wakefield), Ed Balls PM (Normanton), Shahid Malik MP (Dewsbury) and Jon Trickett MP (Hemsworth). The MPs collectively were raising concerns about the capacity and relationship of services across the three sites of Mid Yorkshire Hospitals Trust (MYHT), and were seeking an independent review. The Secretary of State’s response was to invite NCAT to advise the local and regional NHS to ensure they offered the best clinical care across Wakefield and Kirklees.
Terms of Reference (from Tim Barton, Reconfiguration lead, NHS Yorkshire & the Humber) • • •
Advise the SHA on service and clinical implications, risks and benefits of the proposed service configuration Provide the SHA with a view on the clinical safety, capacity and sustainability of the proposed service models Assure the clinical quality and capacity of intermediate care proposals, advising on whether the plans will ensure the demand is met at the right standard Comment on other issues of clinical efficacy and efficiency in the configuration as a whole, in the context of the new economic environment Be mindful of the policy, logistical, financial, estate and capital constraints in which the local health economy is currently working
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Background to Review See above. The case for change was considered in the previous NCAT report Documents Received: 1. Previous NCAT report on visit 19-20 May 2009 2. Two briefing notes prepared for the Secretary of State outlining recent issues; Letter from SofS to Yvette Cooper confirming review (also sent to all local MPs) ; Press release from local MPs 3. Proposal for alternative service configuration from local CEs (and covering letter) 4. MYHT Development Plan Service Configuration – Board Meeting 23-3-10 5. Independent Review of Pontefract Elective Treatment Centre February 2009 (Dr Goodwin) 6. Kirklees and Wakefield District Partnership Board 19-5-09 Intermediate care failsafe plans 7. Intermediate Tier Service Review draft 11 dated 16-1-08 8. NHS Wakefield District Community Intermediate Tier beds review January 2010 9. NHS Wakefield District Systems Specification – Intermediate Tier Beds January 2010 10. Letter from Alan Wittrick, Chief Executive NHS Wakefield to Bill McCarthy Chief Executive NHS Yorkshire & the Humber dated 24-5-10 11. Clinical models of care for use in Pontefract Hospital 2009 dated October 2009 12. Health Gateway Review 0 – Strategic Assessment dated 29-5-09 configuration whilst Dewsbury business case on hold that went to PCT boards. Papers presented at visit 1. NCAT briefing – revised bed configuration, Michele Ezro 22-6-10 2. The Mid Yorkshire Hospitals NHS Trust report on length of stay for Trust Board June 2010 3. Agreed actions from the Joint Health Scrutiny Committee 15-6-10 People met: Chief Executives and Medical Directors Ann Ballarini Deputy Chief Executive NHS Wakefield District (WD) Michele Ezro Assistant Chief Executive MYHT Mike Potts Chief Executive NHS Kirklees Julia Squire Chief Executive MYHT Dr David Anderson PEC Chair NHS Kirklees Prof Tim Hendra Medical Director MYHT Dr Mark Napper Medical Director NHS WD Intermediate Care Helen Mortimer Richard Sewell Moya Emery James Harwood Michele Ezro Elaine Morris Diane Edwards
Director of Quality & Performance NHSWD Head of Urgent Care and Out of hours cares, NHS WD Associate Director of nursing (Medicine) MYHT Associate Director of Operations (Medicine) MYHT Assistant Chief Executive MYHT Locality Manager, Intermediate Tier WDCHS Associate Director of Nursing (Surgery) MYHT
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Commissioning Group Dr Phil Earnshaw PEC Chair NHS WD Dr David Anderson PEC Chair, Kirklees Jackie Bell Senior Commissioning Manager NHS WD Anne Rico EHCC/WWC – Federation Lee Beresford Head of Commissioning Ann Ballarini Deputy Chief Executive, Director of Surgery NHS WD Local Authority Elaine McHale Public Engagement Betty Rhodes Andy Wood
Corporate Director – Family Services WMDC (member of the Partnership Board) chair of OSC at WMDC support officer
Paediatric and maternity services Mr John Jolly Consultant in Obstetrics and Gynaecology MYHT Dr Matt Shepherd Head of Service – Acute and Emergency Medicine MYHT Miss Katherine Reiss Consultant in Obstetrics and Gynaecology, Clinical Manager Gynaecology Dr Simon Enright Group Clinical Chair CSG3 Dr Karen Stone Consultant Paediatrician, Head of Clinical Services, Children (Michele Ezro and Tim Hendra present) Emergency Care Dr Richard Jenkins Dr Simon Enright Prof Tim Hendra Dr Matt Shepherd Mr S K Sundaram Helen Dowdy
Chair CSG1 Chair CSG3 Medical Director MYHT Head of Services – Acute and Emergency Medicine MYHT Head of Services – Surgery Associate Directory of Strategy, NHS Yorks & Humber (Michele Ezro present)
Prior to the meeting the NCAT chair had a phone conversation with Alan Wittrick, Chair of NHS WD and with Dr Tim Hendra, Medical Director MYHT. Views expressed: Capacity Issues •
We (MYHT, Kirklees and Wakefield PCT) need a capacity review for the failsafe beds to understand how many and what type of beds we might need
We (MYHT) have had a 14% increase in referrals to the Emergency Department in the last year across the Trust and this has led to a 6% increase in acute admissions. Thus we are very concerned there might be a shortfall of beds, particularly on the acute side.
The new buildings are already making a difference at Wakefield and Pontefract. So far not all services have been opened at Pontefract but by January 2011 hopefully the A&E and acute beds will be available. However the scale of the increase in demand for beds was unexpected, with predicted 6000 extra patient spells being required. We may need to revisit how we
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design urgent care. The full business case predicted a 3% reduction in acute activity and upper quartile performance based on 2005/6, recently updated to 2008/9. This did not take into account the increase in acute activity, in part a reflection of increase in the growth of the population. •
There is a need to divert acute activity to Dewsbury to release beds at Wakefield and this can be done in part by GPs in the Osset and Horbury area referring patients directly to Dewsbury. On top of that there would be a need to transfer a further 1200 patients from Wakefield and Pontefract to Dewsbury. We struggle for A&E cover throughout the trust at mid grade level – vacancies at some sites are never filled.
Politicians continue to cite the three promises made about Pontefract Hospital when these may not be relevant to present financial plans or how we use hospital beds in the future. The three promises include 90% of the Pontefract hospital activity determined in 2007 would be able to continue to use the Pontefract Hospital, that 40% of medical activity was retained and that there would be 120 hospital beds.
Concerns raised outside of the meetings that the recommendation in principle to secure 50 failsafe beds commissioned for 1-2 years to ensure the safe transition of the hospital reconfiguration. If the beds were in a number of locations, the commissioners would have to commission additional therapy and nursing services than those needed for the present contracted capacity.
There was disappointment at the result of the tendering process for the intermediate care beds as it was a restricted tendering process with only one decent bid, which was 25% above budget. There was a belief from soft market testing that there were more providers out there. There are continuing concerns about affordability of the plans as the PCT would have to pay 25% above the budgeted costs.
There was a continuing concern about what the “system” was doing to address front-end demand, but a recognition that more work needed to be done on this. Clearly the future was about controlling demand but there are now timing and alignment issues about “plan B”. (NB this refers to changes to the reconfiguration plans once it became clear that the new build on the Dewsbury site to accommodate increased cancer activity was not feasible).
Transfer of maternity services had yet to take place. Consultants were expecting that the midwife led service at Pontefract would attract 500 deliveries per year, and that numbers of home births would remain low – 12% of total. There were concerns, with the new build available at Wakefield, mothers would be drawn to this service and that those mothers who would previously have been seen at Dewsbury might now return to Wakefield in view of the modern services available. There were worries that the numbers of deliveries may rise above 4000 at Wakefield in the fullness of time. There were also concerns about the capacity of the gynaecological unit.
Intermediate Care •
Whilst it is good news that we are bringing on stream 70 intermediate care beds, the local authority is closing two care homes with 50 beds so overall
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there may not be much difference in the number of intermediate care beds available. •
Intermediate care plans were predicated by the need to replace 100 beds of activity in the acute trust. The PCT have invested in community geriatricians, up to 30 PAs of consultant cover and improving the number of nursing providers but still there was a need for ensuring 24 hour GP cover for the intermediate care facility. It is expected that other community support would be available, for instance giving intravenous antibiotics and 48 hour fluid therapy. It is possible there may be an increased requirement for consultant geriatrician support and/or reorganisation of current job plans.
There is a need for clear vision for the failsafe beds but these should be provided with a lower level of acuity than that required for intermediate care and could be spot-purchased. A clear-cut plan is required for the timing and availability of these beds
Stakeholder views •
Local GPs were strongly supportive of the plans, they had traditionally used different providers, particularly those on the south east edge of the Trust, such as Doncaster, Barnsley and occasionally referring north of the Trust to Leeds. Their view is that the Trust should just get on with it and make the changes needed.
Overall it was felt that local GPs were excellent but urgent access to GPs was not great. More work was required on admissions avoidance schemes. Because of this, older people were turning up at Emergency Departments and there needed to be ownership by GPs of the urgent care agenda.
The main concern for local GPs was availability of beds so that elderly patients could be admitted to be sorted out. Maintaining local access to general services was seen as more important than retaining the existing range of specialties. Local GPs were happy with the concept that Wakefield and Dewsbury would bear the brunt of acute services, and that Pontefract should concentrate on being a diagnostic and treatment centre, with GP-run community beds.
Both local authorities strongly supported the plans of the Trust and PCTs and were full members of the partnership boards. There had been plans for some years now to close the two short-stay respite centres and this could be easily done because of the increased re-enablement plans the local authority was putting in place. Thus the local authorities’ expectation was there would be no impact on intermediate care beds because of the closure of 50 beds in two short-stay respite centres. The local authorities were very confident of their plans and transfer of services.
The local Overview and Scrutiny Committees were very positively engaged with the issues. Their main concern was about transport for patients, especially for those in the south east of the area travelling to Dewsbury. They were strongly supportive of the plans for orthopaedic trauma. A further critical issue for them was the availability of failsafe beds to ensure transition was smooth. If it was not clear to the OSC that transitional plans were robust they would reconsider their position.
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Yorkshire Ambulance Trust had engagement at the beginning of the process and had regular monthly meetings with the Trust and PCT. There were recognitions about the resource issues of transfer and the need to commission these appropriately. These discussions were underway.
Site configuration •
The future of Dewsbury Hospital is a concern. The plans for MYHT mean that the future of Dewsbury is integral to the secure financial planning and service provision for the whole Trust.
Palliative care support in the trust is of a good level and available for all noncancer patients.
There is a requirement that patients understand the three separate roles of the three hospitals within the single healthcare community served by MYHT.
A&E services were increasingly difficult to maintain on 3 sites. Medical rotas were difficult to maintain and, with changing career plans, the availability of staff grade doctors, which presently staff Pontefract, were becoming more difficult to identify. In order to ensure patient safety on the Pontefract site the trust had had to opt for an extremely expensive solution in providing 24 hour consultant anaesthetic support. Paying for this service meant there was less money available to improve other services; it might not be a sustainable option - identifying people to take on this particular job might be difficult in future.
Paediatricians were having problems sustaining separate on call rotas with three-site provision. Any acutely ill children identified at the Pontefract site would be discussed with the consultant on call at Wakefield and, if necessary, transferred immediately. There were some concerns about patient safety with this arrangement. There will be separate paediatric and NICU rotas at Wakefield and a single paediatric rota at Dewsbury. Ideally the paediatricians would like to centralise the inpatient paediatric services on one site. This would help them deal with the workforce problems, particularly at Dewsbury, where there was difficulty in recruitment to middle grade jobs.
The surgeons across the trust recognised that changes needed to happen to ensure a safe sustainable surgical service supporting the acute admissions. Their favoured solution was one surgical rota with all acute surgical admissions to one site. They recognised this was not politically acceptable but felt this made the most sense from a patient safety and sustainability point of view.
Discussion and analysis Intermediate Care Intermediate Care should be viewed as a whole systems /pathway approach, recognising the need to have capacity in community services to increase patient flow through the system. The flow through acute beds into intermediate tier beds and
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community services is vital if the reconfigured beds in the acute trust are to realise their potential. The earlier supported discharge of patients from the acute hospital will present different challenges than the present group of patients accessing the step down beds. To maximise the potential of patients and their safe care management an increased level of medical support would be required. Therapy and nursing staff would also require access to professional training and development programmes to enhance their skills to meet the needs of this group of patients to ensure improved patient experience and better outcomes. NHS Wakefield has started work to deliver alternative solutions to acute care but it is fair to say that this has concentrated on step down from hospital. There are clear opportunities to enhance work with GPs through PBC consortia and PBC Federations to develop more services in primary care and build on the work of a number of GPs around the patch to deliver consistent robust admissions avoidance with the opportunity to step patients up into the intermediate tier beds. The proposed closure of the 50 Local Authority beds and the reinvestment of the saving into re-ablement services is essential to deliver care for people in their own home which is the preference of most older people. Up to 50 failsafe beds have been proposed to ensure the safe transition of the hospital reconfiguration in 2010/11. Further work needs to be done to determine the nature of patients who would be able to utilise these failsafe beds ensuring patient safety. It became clear during the interviews that where elderly intermediate care patients received their care was very important. The distance which relatives would have to travel may result in less contact and has the potential to have an adverse effect on patient outcomes and experience. Urgent and Emergency Care There are currently about 190,000 A&E attendances a year across Pontefract, Pinderfields and Dewsbury Hospitals. The plans to retain three fully operating Emergency Departments should ensure that services are safe but come at an additional cost to the PCTs of ÂŁ3.8 million. Given the scale of the activity, a more sustainable model would be to have two fully operating Emergency Departments and an urgent care centre. This would enable the ÂŁ3.8 million to be reinvested in additional health care services. We have serious doubts about the sustainability and continued clinical safety of the Pontefract acute service. A full Emergency Department service needs to be supported by on site medical, surgery and paediatric teams, with adjacent intensive and high dependency units. It must be clear how the unit links to acute O&G and trauma services. Whilst the novel arrangements (please see previous NCAT report) to provide out of hours cover and linkages to the main paediatric services are not unsafe it depends on a triage of cases; firstly self-selection by the general public, secondly identification of appropriate cases by the ambulance services and thirdly clinical triage by the resident medical officer and the out of hours anaesthetists. We do not think that this model is the correct way to proceed for the future. Much of the local population needs in Pontefract could be addressed safely and be sustained by the development of an urgent care centre (run by primary care) and a minor injuries
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unit (linked to Wakefield and Dewsbury) which could be nurse led. We have formed the view that patients who are seriously sick and/or require admission to an acute bed should, in future, be referred to the fully fledged emergency and acute care services at Wakefield and Dewsbury where there are teams of clinicians with appropriate support who can deliver the complex high quality care needed. Consideration will also need to be given to how sustainable emergency general surgical services can be provided across the Pinderfields and Dewsbury sites. Vascular surgeons already have a separate on-call rota and as time goes on it is increasingly likely that breast surgeons will want to withdraw from the emergency oncall rota. In order to run two separate emergency surgery on-call rotas the Trust will need a minimum of 6 surgeons on each rota. Currently there are 8 surgeons on the on-call rota at Pinderfields and 6 at Dewsbury. However, 3 of these are breast surgeons and 1 is a â€˜generalâ€™ general surgeon and the viability of two separate oncall rotas is likely to be challenged in the next few years. There are currently about 7,000 births a year across Pontefract and Dewsbury hospitals, with plans to develop a stand-alone midwifery led birthing unit at Pontefract when the inpatient obstetric services transfer to the new facilities at Pinderfields hospital. The aim is that the midwifery led unit at Pontefract will have 500 births a year and it will be important that this figure is achieved, in order to ensure the viability of that unit and to ensure that capacity pressures do not emerge at Pinderfields hospital. It is also worth commenting that the option of creating a single maternity inpatient unit across the three hospitals (which was suggested by some) is unlikely to be either acceptable to the public or warranted from a clinical safety perspective, provided sufficient emphasis is placed on maintaining high quality inpatient services at Pinderfields and Dewsbury. The same is not necessarily true, however, for paediatric services. Increasingly, the number of hospitals providing full inpatient paediatric services is likely to reduce. In part this is driven by difficulties in staffing the existing number of inpatient units, particularly at middle tier level, but it also a reflection of the reduction in the number of children who actually need to stay overnight. Where such changes have been made, or are being considered, they are usually accompanied by the development of paediatric assessment units, providing a more consultant delivered service, and the extension of community services. Conclusions 1. The hospital services as presently planned are not unsafe but we have concerns about the sustainability and hence future clinical safety and financial viability of the proposals. 2. We have concerns about the capacity at the front end of the hospital, ie acute admissions, when the new PFI buildings come on stream. There is a risk that, with the present configuration of beds, there will be extreme pressure on the acute beds, particularly if the Trust fails to achieve its goal of upper quartile performance and demand continues to grow. 3. There is a need for further failsafe planning for 2010/11. Present planning places the failsafe beds within intermediate care with a low intensity setting. Whilst this might help the Trust achieve better average length of stay within the acute beds, we have concluded that there are still significant risks. We are concerned that the present plan relies solely on the spot purchasing of
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these beds. A whole systems approach is required to fully understand the need and placement of the acute beds supported by intermediate care and other facilities. There is a requirement for a further review of the existing emergency and urgent care plans to address the problems of increasing demand. . 4. There needs to be an agreed configuration of services of the three hospitals (Pontefract, Wakefield and Dewsbury) so that the public is fully aware of the services that are offered, and how these fit together to deliver an overall package of quality services for the population of Kirklees and Wakefield PCTs. This plan should address the issues of acute and urgent care, elective care, intermediate care and rehabilitation. The public need to know which hospital to go to when they have a problem. This strategy needs to be clearly communicated over the coming months and years so that people do not present themselves inappropriately at the wrong site. 5. Whilst we fully understand and have been supportive of where the Trust is presently with its plans to reorganise its services, we do not think the plans for Pontefract are sustainable. Thus, over time, Pontefract should stop offering limited emergency services and a clinical decisions unit. There are issues of safety in admitting patients who are acutely ill to the CDU at Pontefract. In future all acutely ill patients should be transferred to the one of the other two sites. The trust should then design a future for Pontefract which is built around delivering a minor injuries service and urgent care along with elective care and management of long term conditions (eg rehabilitation services, outpatient services, community support services). We think this would be a much stronger vision for the Pontefract site which would then have a sustainable future providing safe, high quality care and should retain much of the overall clinical activity within Pontefract. The Pontefract Hospital services should be seen as one component of the overall services offered to the populations of Kirklees and Wakefield by Mid Yorkshire Hospitals Trust. The Trust needs a strong message to the population that it will provide high quality equitable care to everybody within the PCT catchments, and that the opportunity costs of spending money unwisely at the Pontefract end will have adverse effects on other services elsewhere in the Trust. 6. This vision for the future should describe clearly the split of services between Dewsbury and Wakefield. We suspect that over time the services at Wakefield will become increasingly hot, and that the acute end of services will remain focused on Wakefield, accepting that there will continue to be an Emergency Department and a full obstetric service at Dewsbury. This will enable the Dewsbury end to focus more on elective care, for example elective orthopaedics, and for the Trust to make better use of existing capacity. This has considerable advantages in terms of patient safety, eg fewer infections occur in planned elective care units, and they are more cost efficient. The public will need to understand that producing care more efficiently will mean that more monies are available to develop better services. 7. It will prove difficult to maintain an acute surgical presence on both ED sites. The surgeons should look at ways of having a single acute surgical rota at consultant, mid grade and junior level which delivers an in hours and out of hours service to both hospitals (Wakefield and Dewsbury). For instance it might be necessary to transfer some acute surgical patients from one ED site to the acute operating site. Flows of patient numbers would determine how
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this would work, ie whether one site is always the acute operating site, or whether it rotates between sites. 8. For paediatric services, we think there is likely to be merit in considering a single inpatient service at Pinderfields hospital, whilst ensuring that the vast majority of childrenâ€™sâ€™ services continue to be provided locally. For maternity services, however, we are not at this stage convinced of the merits of developing a single inpatient unit and would suggest that emphasis is placed on maintaining two separate but linked inpatient obstetric units, together with the midwifery led birthing unit at Pontefract. 9. We are concerned about the transitional funding arrangements. The PCTs and Trust need to agree these as speedily as possible. 10. The outcome of the tender for intermediate care is disappointing and the PCTs may be paying over the odds for the service. There is little evidence of admissions avoidance, plans for clinical cover need to be secure and arrangements for transfer, step up and step down need to be fully worked through with appropriate clinical protocols to ensure that only those patients who will benefit from intermediate care, and can be safely managed within an intermediate care facility, are transferred. They should ensure regular (?daily) multidisciplinary meetings to agree timely discharge plans. Recommendations We recommend that: 1. MYHT, with the two PCTs, continue to develop their plans for the 3 sites. As a matter of urgency they should look again at the bed numbers provided for acute care to ensure that a safe service will continue with the commissioning of the new facilities and factor in the risk of not achieving upper quartile performance. Of necessity this will require a whole systems approach which should review the patient flows between hospitals and specify clearly the role of the intermediate care beds and 2010/11 failsafe beds. 2. MYHT, working with the 2 PCTs and other key stakeholders, should describe a vision of the future which specifies the roles of the 3 hospitals, taking into account the conclusions of NCAT as above. 3. Plans for the use of intermediate beds are more fully developed so that it is clear which patients can step up and which can step down to use these facilities, and with what outcomes. Clinical protocols will need to be put in place and shared with appropriate clinicians across the Trust. It will follow from that piece of work what clinical support is required.
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