Dr Jill Evans Dr Simon Williams 17 May 2013 1. …whether it wishes to go out to consultation on the basis of the pre-consultation business case The final.

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Dr Jill Evans Dr Simon Williams

17 May 2013

…whether it wishes to go out to consultation on the basis of the pre-consultation business case

The final decision on consultation will be taken by CCGs with consideration of the consultation document and Equality Impact Assessment

Today the Governing Body is asked…

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Why do local services need to change?

• Healthcare is constantly changing, yet health services have stayed the same

• The safety and clinical quality of services depends on the day, time of day or night, and the hospital.

• If someone needs emergency care, it’s important the most senior, experienced and specialist staff are on hand 24/7

• Concentrating teams of highly trained staff at fewer hospitals makes services safer and better

• We also want to provide more services in the community

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We are failing to meet Royal College guidelines and London Quality Standards.

• The most senior, experienced and specialist doctors and nurses should be available at weekends as well as during the week

• Maternity units should have the most senior, experienced and specialist staff available on labour wards 24 hours a day, during the week and at weekends

• We can provide better quality care by carrying out routine operations in separate dedicated facilities.

We could save lives by doing things differently

We want to deliver better care

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• We have considered keeping services at every site and trying to deliver the recommended improvements across all five sites.

• There are not enough qualified, senior people in training. If these trainees did exist, we could not afford the extra staff

• We would not be able to meet the standards of care and safety that we want for our patients.

• We would overspend our budget to the point where our services would reach crisis point

• We would not be able to invest as much money in services outside hospital

Why can’t services stay the same?

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• Advances in technology and treatments mean an increasing need for specialist staff and equipment.

• It’s difficult for every hospital to have every type of specialist staff, and even if they did, there would not be enough patients at each hospital to treat to maintain their skills.

• Patients are already benefiting from centralised services for the treatment of heart attacks, stroke, cancer and major trauma with designated centres for each of these. Survival rates are now much higher as a result.

Why do we need to centralise services?

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Is this about saving money? • We spend public money so value for money is important to us

but this isn’t what’s driving this programme.

• For us, this is an opportunity to raise standards of care for our patients.

• Funding has not been cut but we do need to make our money go further and respond to our population’s changing needs

• People with long-term conditions can be treated in the community and in their own homes.

We believe creating specialist centres of excellence will improve care

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• Surrey Downs clinicians joined the programme following the halting of the proposed merger between Epsom Hospital and Ashford and St Peter’s.

• The review has been clinically led by over 100 doctors, nurses, midwives and other clinicians from Surrey Downs and south west London who formed clinical working groups.

• Clinical working groups have made a series of recommendations about how care should be provided, based on best practice and the latest clinical evidence.

Where are we now?

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Services remain at all five hospitals

More and better services outside hospital

Three expanded emergency departments

Three expanded maternity units led by consultant obstetricians with co-located midwifery led units

A separate, stand-alone, midwife-led birthing unit for women with low risk pregnancies if public support and viable

A network of children’s services with St George’s Hospital at its centre. This would include inpatient beds, children’s A&E and children’s short stay units at the three hospitals with emergency services.

A planned care centre for all inpatient surgery, except the most complex, on a separate site from emergency care

The clinical recommendations

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• One major acute teaching hospital, at St George’s, providing stroke, heart attack and major trauma services. It would also have a A&E, obstetric-led maternity unit, specialist children’s inpatient unit and a children’s ward

• Two major acute hospitals, at Kingston and either Croydon or St Helier, providing emergency and urgent care and obstetric-led maternity services with an attached midwife-led unit. These hospitals would also have children’s inpatient wards.

• One local hospital with a planned care centre, urgent care centre, diagnostics, outpatients and day surgery at either Epsom or St Helier

• One local hospital with an urgent care centre, diagnostics, outpatients and day surgery at either St Helier, Epsom or Croydon

What changes are being proposed?

This involved a carefully structured, five-stage process:

1. Development of non-financial criteria and options Clinicians and patient representatives were brought together to decide how each factor should be weighted at three events. When Epsom Hospital was included, a large-scale event was organised at Epsom racecourse to revisit the weightings

2. Financial ‘hurdle’ to rule out options that would not work financially Financial assessment of all available options was carried out by a specialist team of financial experts and agreed by the directors of finance

3. Non-financial assessment Remaining options were assessed by an expert NHS panel, who worked with data relevant to the assessment of each of the options against the non-financial criteria

4. Financial assessment Remaining options were assessed financially by our specialist team of financial experts and accountants and agreed by the directors of finance

5. Recommendation by the Better Services, Better Value Programme Board Our Clinical Strategy Group and Programme Board looked at the outcomes and held further discussions about the best way to shape services in the future

How were the options developed?

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The three options

Rank Croydon Epsom Kingston St George's St Helier

Preferred Major acute hospital

Local hospital with elective

centre

Major acute hospital

Major acute teaching hospital

Local hospital

The preferred option

Configuration of the preferred option• St George’s is a major acute teaching hospital• Kingston and Croydon are major acute hospital• Epsom is a local hospital with a planned care centre• St Helier is a local hospital

Rationale• This option scored highest on the overall financial and non-financial appraisal• This configuration where the local hospital with elective centre would be located

on the Epsom site plays to the strengths of Epsom’s existing estate and capability by locating the elective centre there, and has a relatively low capital cost which is reflected in the high financial appraisal score

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Configuration of the alternative option• St George’s is a major acute teaching hospital• Kingston and Croydon are major acute hospitals• St Helier is a local hospital with a planned care centre• Epsom is a local hospital

Rationale

• This option scored lower than the preferred option and slightly higher than the least preferred option in the overall financial and non-financial appraisal.

• Scores lower in the financial appraisal than the preferred option, as it would require a significant additional in-area capital investment of approximately £100m which reflects the costs of building a new elective centre at St Helier.

• However, this option faces considerably fewer delivery challenges than the least preferred option and is therefore the next preferred option

The alternative option

Rank Croydon Epsom Kingston St George's St Helier

Alternative Major acute hospital Local hospital Major acute

hospital

Major acute teaching hospital

Local hospital with elective

centre

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Configuration of the least preferred option• St George’s is a major acute teaching hospital• Kingston and St Helier are major acute hospitals• Epsom is a local hospital with a planned care centre• Croydon is a local hospital

Rationale• This option scored lower than the preferred option and slightly higher than the

alternative option in the overall financial and non-financial appraisal• However this option is least preferable because it has a high level of associated

delivery risks. This is primarily due to proposed changes to emergency and maternity services in Croydon, which would result in considerable activity flows to King’s College Hospital and the issues associated with managing this• This option has the highest estimated capital costs for non BSBV trusts

The least preferred optionRank Croydon Epsom Kingston St George's St Helier

Least preferred

Local hospitalLocal hospital with elective

centre

Major acute hospital

Major acute teaching hospital

Major acute hospital

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• Local doctors and midwives believe that a stand-alone midwife-led unit at one of the two local hospitals would be a clinically safe option

• This unit could support at least 1000 women to give birth per year, depending on where it is located

• It would be for women who are suitable for a home birth and who are at low risk of having complications during childbirth.

• It may be potentially expensive to run if not enough women were to give birth there. First we need to work out if there is sufficient demand to make this viable

• We want to continue explore how local people feel about the development of a stand-alone midwife-led unit

Development of a stand-alone midwife led unit

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What could still be provided at Epsom?

Community inpatient bedsFull suite of rehabilitation/ reablement from NHS and social care

DiagnosticsX-ray, ultrasound, CT and MRI scanning

Outpatients•Retain full range of services and greater range of providers

Day surgery Other services•Mental

health•Community

paediatrics•Primary care

support

Urgent Care Centre – retaining >50% of current A&E work•Access to a range of therapeutic and diagnostic services including pathology, blood testing and X-ray• Operating up to 24/7 based on demand

Links to Community Assessment Unit, virtual wards and other community hospitals

Long-term conditions and support for older people

Enhanced Elective Centre•Orthopaedic elective cases•Other surgical elective cases and ITU

Epsom could also have

Stand-alone midwife led unit subject to demand and viability

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For all options

• It is expected that around 80% of the patient attendances would still be at Epsom Hospital

• Epsom Hospital would become a local hospital that ensured the majority of people could continue to access urgent care services, diagnostics, outpatients and day surgery. However it would have an urgent care centre instead of its current A&E and it would no longer have a full maternity unit

• Under the preferred option, Epsom Hospital would have a planned care centre

• The hospital would have an urgent care centre which would continue to treat patients (including children 0-19 years) with minor injuries or illnesses, such as broken bones, bites, infections, sprains and wounds.

• Investment in community services, and providing more healthcare closer to people’s homes, has already started and this will continue

What would these changes mean for local people?

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• We are committed to raising standards of care for all our patients and our other Surrey hospitals are working to achieve this.

• Surrey providers have been asked to comment on their ability to cope with additional activity and their ability to also raise their standards to meet Royal College guidance.

• Surrey and Sussex Healthcare Trust, Ashford and St Peter’s and the Royal Surrey County Hospital have confirmed they are all working towards these standards, recruiting more staff where necessary

Investing in Surrey hospitals

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Expected impact on travel times For all options

• Between 480,000 and 570,000 residents will have a different nearest major acute hospital than currently

• This roughly equates to 75,000 – 80,000 A&E attendances per year going to a different hospital

• The main affected areas are around Epsom, Ewell, Banstead, Leatherhead, Carshalton, Croydon, Purley, Wallington and Coulsdon

• Whilst travel times to a nearest major acute will increase for these areas, all residents in these areas should be able to reach a major acute hospital within:• 25 minutes by car• 100 minutes by public transport (99% of the population

within 60 minutes)• 20 minutes by blue-light ambulance

• There will be no change in travel times for outpatients, primary care or day surgery and access to Urgent Care Centres will be the same as for A&Es currently

Affected areas

Travel time impact

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• We would not be able to meet standards set by clinicians based on Royal College and London Quality standards.

• All of our hospitals have quality issues at the moment and some of these would not be addressed

• Local health services would not be financially sustainable

• We would not be able to invest in community services and improve care for people with long-term conditions

• We would not be able to deliver the needed improvements in services. The financial position would mean there would have to be other savings which would affect the services delivered locally

What if we didn’t make any changes?

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• A Consultation Plan has been developed and approved by the Joint Health Overview and Scrutiny Committee, subject to some minor comments and amendments

• Detailed individual consultation plans for each area have been created to help us seek the views of as many people as we can

• The plan includes roadshows and meetings across the local area and many opportunities for local people to tell us what they think

• Where possible we are happy to attend your meetings if you want us to

How will we involve local people?

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• Each of the seven CCGs involved in the review are considering the options that have been put forward and whether they would support a move to consultation

• If each CCG agrees to consultation, a date for a 14 week consultation will be announced

• We want as many people as possible to be aware of the consultation and to respond

• If the proposals are agreed following public consultation, there would be no changes to existing services until expansion work at other hospitals is complete and following further investment in community services

• Changes would not be implemented immediately – it would take four to five years to develop the proposed services

What happens next?

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…whether it wishes to go out to consultation on the basis of the pre-consultation business case

The final decision on consultation will be taken by CCGs with consideration of the consultation document and Equality Impact Assessment

Today the Governing Body is asked…