Appendix 3.19: Horton Strategic Review Powerpoint Handover

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Strategic review of the Horton General Hospital
DRAFT – Handover Document Key supporting analysis and evidence
1 July 2016
11
1. The catchment population and its needs
2. Current service provision
4. Strategic options for the Horton
5. Analysis to support evaluation
Contents
22
Summary - the catchment population and its needs
The Horton General Hospital serves a catchment population of around 170,000 people in North Oxfordshire
The population is largely healthy and wealthy but there are pockets of deprivation around Banbury, Bicester and Chipping Norton.
The Oxfordshire population (of which the catchment is a subset) has a similar prevelance of chronic conditions and disease as the England average
The population is projected to grow to around 190,000 by 2025 with the over 70s projected to comprise 31% of the population, compared to 21% today.
The over 70s account for almost a quarter of acute hospital activity. Therefore due to the growth in this population segment if care models remain similar to today activity would grow by up to 3% per annum over the next 10 years
Older people require new models of care with a much greater focus on prevention, coordination of multi morbities and care closer to home as multiple national reports have shown
33
"The Oxford University Hospitals NHS Foundation Trust Proprietary and Confidential"
The Horton General Hospital has a catchment population of ~170,000 people
30 of these wards are in the Oxon area, 7 are in Northamptonshire and Warwickshire
44
The catchment population has relatively high life expectancy
SOURCE: PHE local health tool
Life expectancy at birth in females 2008-12 (lighter colour is associated with lower life expectancy)
Life expectancy at birth in males 2008-12 (lighter colour is associated with lower life expectancy)
55
Though pockets of deprivation exist in the areas around Banbury, Bicester and Chipping Norton
SOURCE: PHE local health tool
GCSE educational attainment - % of pupils achieving 5 A-C grades in 2011/12 (lighter colours are associated with higher deprivation)
Percentage of population living in low income families in 2010 (darker colours are associated with higher deprivation)
66
Prevalence of diseases – Oxfordshire CCG vs. England average
Chronic condition and disease prevalence profile in Oxfordshire similar to England Average
0.7
5.9
Oxfordshire CCG % England %% of population1, 2013/14
NOTE: these estimates are based on GP registers and therefore does not include undetected diseases, which may represent a significant burden
77
The current catchment population of ~ 170K is expected to grow to 192K in 2025, with the over 70s growing >5 times faster than the under 70s
49
19-49
<19
67
SOURCE: OCC (Oxfordshire Insight of Oxfordshire County Council) projections for Oxon wards; ONS District projections for non-Oxon wards
0.2%
5.6%
0.9%
3.9%
1.4%
Population projection
There are planned major developments in transport infrastructure and economic development in Bicester.
A substantial increase in housing is planned for Bicester and Banbury between now and 2030.
88
People over 75 years of age (~8% of total population) account for ~21% of all elective and ~22% of non-elective admissions in Oxfordshire
Acute activities by age group %; 2014/15 (2013/14 A&E)
28
29
9
8
12
54
50
41
48
56
53
7
23
9
21
11
16
7
16
12
16
14
14
11
10
85+65-74 75-8419-64<18
24
8
21
9
9
12
56
53
46
49
54
54
8
21
10
21
12
17
7
14
13
17
14
13
11
10
4
100%
5
5
5
%
Estimated prevalence in 2015 and projected growth rates for selected conditions
By 2020, 1 in 13 of the local residents are expected to have diabetes and 1 in 17 to have Cardiovascular Disease
8.0
0.6%
8.5
0.7%
8.07.5
2.8
0.5%
2.62.22.1
0.5%
Diabetes
Stroke
CVD
COPD
EnglandOxfordshire CCG1
1 COPD, Stroke and CHD figures based on figures modelled for LA (Cherwell, Oxford, South Oxfordshire, Vale of White Horse and West Oxfordshire)
1010
SOURCE: ONS/OCC population projections, HES data 14/15, team analysis
Assuming similar models of care as today, a growing and aging population would result in up to 3% per annum growth in activity
1.2
1.5
1.6
1.2
1.6
1.8
2.6
3.1
Estimated demographic growth by service line % CAGR; 2015/16 to 2025/26
1111
Summary of example quality standards for frail elderly / people with long term conditions (1/2)
Standard Source
All people over the age of 65 or with long term conditions will be risk stratified with appropriate pro-active care plans but in place for moderate and high risk individuals
GPs to provide case management, and proactive personalised care plans, for the most vulnerable patients identified through risk stratification, GMS Contract (Direct Enhanced Services) 2014
All moderate and high risk people will have a named care coordinator who will support them in self-care and ensure continuity of care through health services
Patients with long term conditions should receive support to build the skills to manage their own health, NHS Mandate 2013
Vulnerable patients should have a named accountable GP and care coordinator, GMS Contract (Direct Enhanced Services) 2014
All people over the age of 75 and people with multiple long term conditions will have a named GP
All patients aged 75 and over will have a named accountable GP, GMS Contract 2014/15
In the event of a crisis, people will be appropriately triaged, and where suitable, be assisted by a multidisciplinary rapid response team which will provide them with care in their home, and where appropriate, put in place short term home support to aid recovery at home as an alternative to hospital admission
Birmingham Community Healthcare NHS Trust, 7 Day Rapid Response Service Case Study, NHS Improvement 2011
Acute staff will have appropriate training in identifying dementia
By March 2015, NHS organisations are expected to have made particular progress in the diagnosis, treatment and care of those with dementia, NHS Mandate 2013
Have access to telecare to provide them with support and advice in their own homes
Dyson (2014) Improving General Practice: A Call to Action – Phase One Report
NHS belongs to the people: Call to Action
1212
Summary of example quality standards for frail elderly / people with long term conditions (2/2)
Standard Source
Have access to short term intermediate care in the event of a crisis
DOH (2001) National Services Framework – for older people
Discharge coordination should start before admission for planned/anticipated surgery cases and at admission for other cases, to reduce prolonged stays, involving the family early and focusing on discharging people to their own homes with appropriate support
Recovery Rehabilitation and Reablement (RRR) programme for early supported discharge and rehabilitation in the community, Integrated care and support: our shared commitment, Dept of Health 2013; QIPP Long Term Conditions, Dept of Health 2012
All people with long term conditions with have access to a specialist nurse or GP to support them
Vulnerable patients should have a named accountable GP and care coordinator, GMS Contract (Direct Enhanced Services) 2014
All people with long term conditions will be offered information and support in self care
Integrated care and support needs to extend beyond traditional perceptions of “healthcare” and “social care” and into areas involving early intervention, prevention, self-care and promoting and supporting independent living, Integrated care and support: our shared commitment, Dept of Health 2013
Patient information should be available to all teams supporting that patient
There are significant benefits from connected information … to providers of health and social care services, to commissioners of those services, and to us as patients and service users. Information Strategy, Dept of Health 2012
1313
1. The catchment population and its needs
4. Strategic options for the Horton
Contents
1414
Summary - current service provision
In addition to The Horton General Hospital, local health services include~ 26 GP practices, 4 community and mental health facilities, a freestanding midwife led unit and 5 walk in centres
The Horton General Hospital currently provides a comprehensive range of typical “DGH” services – outpatients and diagnostics, a 24x7 A&E department (which sees on average just over 100 attendances per day) along with emergency admissions, inpatient paediatrics, obstetrics, elective surgery and critical care.
The Horton is one of the smallest district general hospitals in the country with a number of services rated as “needing improvement” and an estate in need of significant investment. Its patient satisfaction scores were lower in 15/16 than the other OUH sites.
1515
Horton
UCC
Walk-in centers (5)
There are 26 GP practices with 114 GP WTEs in the Horton catchment area
SOURCE: HSCIC, General and Personal Medical Services, England - 2004-2014, As at 30 September; Publication date: March 25, 2015
2,593
3,471
4,329
4,380
5,342
5,742
6,894
7,096
7,166
7,360
7,385
7,773
7,846
9,272
9,390
17,283
2,033
1,464
1,480
1,399
1,419
1,457
1,112
1,568
2,120
985
1,600
1,102
1,451
2,852
1,280
1,943
746
1,574
1,983
# people per GP WTE
Data was not available for 5 GP practices: Bicester Medical Centre, Hmp Bullingdon, Pml neighbourhood hubs, PML neighbourhood hub (Bicester) Chipping Norton drug treatment clinic, PML neighbourhood hub (Chipping Norton)
1717
The Horton Hospital currently provides a full range of DGH services
SOURCE: PLICS 2014/15, Radiology 2014/15 data
Emergency
Maternity
Diagnostics
Other
Elective day cases Elective overnight spells Outpatient appointments
X-rays MRI scans6
Type of activity at Horton Activity per year, 14/15
Activity per day, 14/15
5 -5
-4 -4
1 Full ED service for majors, standards and minors. 2 Adult level 2 and level 3. 3 Obstetrician led unit. 4 Imaging (fluoroscopy, mammography, ultrasound) and lab activity not listed here. 5 1 episode listed in 2014/15 but ~1,500 episodes in 2015/16. 6 MRI activity takes place at Ramsay Treatment Centre on same site as Horton.
Please note all activity (except for some MRI scans) that takes place at Ramsay Treatment Centre is not included here as it is not owned by OUH
1818
Acute activity at the Horton is considerably lower than the national average
250
0
150
100
50
200
51
0
4
2
6
8
3
0
20
5
10
15
5
SOURCE: HES 2014/15
1 Non-elective admissions; 2 Activity for OUH has been apportioned across both sites according to the 2014/15 split, based on PLICS data
JR2
Maternity deliveries
Paediatric spells1
JR
Horton
JR
Horton
Horton2
1919
Horton had an overall rating of ‘good’ by the CQC although some areas for improvement were identified
Culture, ways of working and governance Staff were proud of their hospital and the care they provided
to patients Staff spoke highly of their peers and the support they
received from their line managers Staff worked well between wards to ensure safe staffing
levels were maintained Multidisciplinary team working helped to meet the complex
needs of patients Auditing and monitoring of care ensured improvements in
practice
Critical Care The care and support given to patients and their relatives in
critical care was excellent There were good outcomes for patients in critical care -
mortality was below national averages
A&E The stroke service in A&E followed a clear pathway and
delivered good outcomes to patients
Culture, ways of working and governance The hospital trust should improve support to local staff so
they feel more included and less isolated Clinical notes for patients in the medical wards should
include a records of all agreed care given to patients Decisions made by patients around resuscitation should be
reviewed as required Critical Care The hospital should have cover at all times from medical
staff trained in critical care The provision of an outreach service for critically ill patients
should be revisited The kitchen in the critical care unit should be better secured
from the clinical area A&E The hospital needs to ensure it has sufficient bed capacity
for A&E to meet Government target waiting times Staff, specifically in the A&E department should have
regular training in supporting people with dementia Although all A&E staff were trained in paediatric life
support, guidance said the department should have trained paediatric nurses on duty at all times
Access to services Patients should have access to specialist medical services
when they are needed Maternity services Support for newly-qualified midwives (through their
preceptorship programme) should be improved along with management of the maternity services
Good practice Areas for improvement
SOURCE: CQC 2014
The Horton receives positive patient satisfaction scores, though slightly lower than the Headington sites
SOURCE: Friends and Family Test 2015-16. Response rate varies between 6 to 40%
95
94
97
95
93
98
94
95
95
96
93
92
March
Dec
June
April
Aug
May
Nov
Oct
Sep
Feb
Jan
July
95
96
96
95
96
96
96
97
97
98
97
97
95
96
96
96
95
96
96
96
96
97
95
97
96
96
98
97
96
97
97
96
98
97
96
100
Horton JR Churchill Nuffield
Some of the facilities at Horton site are “unacceptable” according to an independent assessment conducted by a third party
SOURCE: Trust Management Executive Away Day presentation 11th Feb 2016
2323
Contents
– Urgent & emergency care
2424
Summary - pathway improvement elective and diagnostics
Through a series of workshops clinicians considered challenges of the current clinical pathways, reviewed the national guidance where available and studied examples from elsewhere. Through this process they have identified opportunities to improve the quality of care across four pathways for the local population.
Elective and diagnostics
The clinical group has a vision to – Increase choice of diagnostic and elective procedures so that local residents do not have to travel into
the centre of Oxford and provide ‘one-stop-shop’ clinics so that outpatient and diagnostic visits are minimized
– Create an elective facility that has the facilities and volumes to operate efficiently, is attractive to staff and provides a high quality training experience for junior members of staff
There is strong evidence from UK and abroad of the quality and efficiency benefits of creating a dedicated pathway for elective care with standardized procedures and dedicated facilities. Clinical working group considered the case examples including SWLEOC in London and Alfred in Australia as well as the recent Monitor report into opportunities to improve elective care
Currently – Local residents of The Horton General Hospital do not have access locally to high quality diagnostic
equipment, the CT scanner requires replacement and the MRI scanner cannot be used for inpatients. – Outpatient services are very fragmented across North Oxfordshire resulting in inefficient deployment of
staff and for patients are not coordinated with their outpatient appointments – Current elective, or planned care services are very under-utilized with theatre utilization around 70% of
the standard 35 hours of operating per week, 3 MRI scans a day and 33 xrays per day (spread across 4 x ray machines)
– Training recognition for surgical trainees has been removed
2525
Proposals from clinical working group for elective and diagnostic services
Rapid access diagnostics at The Horton General provided closer to home, at a convenient time (e.g., part of “one-stop-shop” clinics)
“One-stop-shop” clinics for outpatient and surgical pre-assessment with diagnostics onsite, closer to home
ToFrom
Difficulties accessing diagnostics – Patients travelling from HGH to other sites for
diagnostics – Patient admitted or kept in hospital to avoid long
outpatient waits for scans – Patients at Horton being transferred to the JR for
in-patient MRI scans Outpatient services uncoordinated with
diagnostic appointments
staff – Day case surgical ward taken up with medical
outliers
Sub-optimal training environment – Competition for training in producers at the JR
plus time pressures on staff to deliver service
Difficulties in recruitment and retention of staff
High throughput, efficiently run elective facilities at The Horton General
Dedicated centre for teaching and training with uninterrupted time to teach and learn - make education one of The Horton General’s sources of distinctiveness
An attractive centre where staff want to work with flexible staffing models that allow cross-site working, but with ownership of the services provided at The Horton General
More elective services available at The Horton for local catchment and beyond
Elective procedures require travel into centre of Oxford with associated transport and parking difficulties
2626
Report: Monitor 2015 on Elective care
SOURCE: Source
External example: Elective Orthopaedic Centre (EOC), has significantly improved South West London’s orthopaedic performance
The EOC in South West London opened in 2004
4 trusts shared vision of creating single, world-class, NHS orthopedic elective centre
Teamed up with a U.S. mentor organization who had done a similar project
Increased capacity from 2,100 annual procedures in 2001 to estimated 5,200 (3,000 joints) in 2013. Now one of the largest orthopaedic centres in Europe.
In 2013 SWLEOC was delivering a £3m surplus annually.
-54 inpatient and 17 PACU beds -Offers major joint replacements, ligament reconstructions, arthroscopies to hip and knee, a full range of shoulder foot and ankle procedures and spinal work. -Focus on flexibility and not ‘cherry-picking’ cases -Uses intelligent procurement methods and leverages position with prosthetics manufacturers -Full day operating lists
Exceeded activity targets Have achieved 18-weeks from March 2008 (96%
Admitted, 98% non-Admitted) Reduced same day cancellations to 1% for clinical
reasons and 0.5% for non-clinical reasons (all admitted within 28 days). (Nat. average 4.3%)
Reduced average LOS to 3.4 days (5.5 for knees, 4.9 for hips, 6 for revisions)
Reduced post-op infection to 0.02% (national average 1.0% to 1.4% dependent on study)
Reduced blood transfusions to well below national average.
Increased theatre utilization from 87% in 05/06 to 97% in 08/09, consistently at 95% in 12/13
Now largest joint-procedure provider in U.K. and possibly Europe
SOURCE: SWLEOC, Updated based on 2013 report https://www.nhsproviders.org/media/1823/swleoc-final-m.pdf
2828
External example: Alfred Health (1/2)
SOURCE: Alfred Health interviews; MJA (2011) Streamlining elective surgery care in a public hospital: the Alfred experience (https://www.mja.com.au/journal/2011/194/9/streamlining-elective-surgery-care-public-hospital-alfred-experience
Executive summary
New model of delivery of elective surgical services designed specifically to provide consistent quality of care and good operational performance
The model is based on a high degree of standardization: – Clarity of complexity/case mix which the
centre can accommodate – with higher complexity patients treated at the tertiary hospital (separate managerial structure but single financial entity)
– 168 protocols for all major pathways – Defined expected length of stay for all
major pathways (usually 3 days maximum) – Peri-operative coordinators responsible for
theatre scheduling (rather than individual surgeons) with suite of theatre scheduling tools and analytics
– Streamlined pre-admission assessment process
Delivery model
A public sector multi-specialty elective only centre with fully dedicated management and resources, co-located with a large teaching hospital providing emergency and specialist elective care
Surgeons work across both organisations (the elective centre and the teaching hospital)
Opened in 2007 in order to address issues at the tertiary centre (The Alfred) including: – Long waiting times for elective surgery – Frequent cancellations or postponements of elective surgery
due to prioritisation of time-critical emergency surgery
Australian national public health insurance scheme, Medicare, provides universal health coverage but private insurance is encourage through taxation and subsidies
Mix of public and private hospitals serving all insurance groups State governments have relatively high degree of autonomy in
administration of health services
External example: Alfred Centre streamlining elective surgery (2/2)
SOURCE: MJA (2011) Streamlining elective surgery care in a public hospital: the Alfred experience (https://www.mja.com.au/journal/2011/194/9/streamlining-elective-surgery-care-public-hospital-alfred-experience)
1 Between February 2005 and 2010 2 Between February 2005 and 2010; By February 2011, HIP rates at Alfred Centre and main Alfred Hospital were less than 1% and 7%, respectively 3 Between quarter ending 30 September 2005 and the same quarter in 2009; Establishment of the Alfred Centre and segregation of the surgical teams have enabled protection of the hospital’s
elective surgery capacity, resulting in fewer cancellations of elective surgery when emergency surgery peaks occur 4 Based on informal surveys of Alfred Centre staff following implementation of new model of care 5 Based on telephone follow-up from September 2008
Background Initiative details Impact
Setting Melbourne, Australia The Alfred, a major tertiary
hospital operating as Australasia’s largest designated trauma service and as elective surgery provider for state of Victoria
Case for change Long waiting times for
patients requiring elective surgery
Hospital initiated postponement (HIP) of almost 30%
Approach Clinical process redesign to streamline perioperative
services initiated in 2006 Construction of Alfred Centre, a separate dedicated elective
surgery and procedural facility collocated on hospital site Primary aims of redesign to:
– Improve timeliness of patient care, specifically by reducing HIP rates and decreasing number of patients waiting for elective surgery beyond nationally recommended waiting periods
– Increase hospital’s surgical treatment capacity Process Surgical care separated into streams to increase service
efficiencies – Specific areas of Alfred Centre and main Alfred Hospital
set aside for emergency, elective short-stay (<3 days) and elective long-stay (>5 days) streams
Surgical care model standardised and protocol-led – Model revised to incorporate patient screening and
allocation to appropriate wards by team of perioperative coordinators; one-day attendance at pre-admission clinic for pre-surgical evaluation; and coordination of individually tailored discharge support before admission
Structure of clinical leadership and dedicated management modified to coordinate all components of new service – Perioperative Services Manager and coordinators for
each surgical unit appointed
Timeliness of care 45% decrease in numbers of Category 2
patients (semi-urgent) waiting longer for surgery than the recommended time of <90 days1
Decrease in combined HIP rate for planned elective admissions from 28% to 6%2
Reduction in median time to time-critical non-elective surgery at main Alfred Hospital as a result of dedicated standalone facility for elective surgery
Length of stay Reduction in combined LOS for top surgical
DRGs from mean of 4.8 days to 2.3 days1
Increase in proportion of successful same- day discharges from 83% to 95%1
Capacity to manage demand Increase of 70% in number of patients
admitted to Alfred Hospital per month for elective surgery3
Morale and satisfaction Improvement in morale among medical,
surgical and nursing staff4 100% satisfaction with new pre-admission
process among short-stay elective surgery patients5
1 2 3
Output from clinical working group: Challenges with current service provision
SOURCE: Clinical interviews
Either acute or out of acute setting(s)
Self-assessment and enhanced self-care Assessment & diagnostics Treatment and intervention Rehab & follow up
ELECTIVE, DIAGNOSTIC & SPECIALIST
Low level of asset utilisation Lower level of theatre and endoscopy utilisation rates at Horton vs. JR site Theatre utilisation is patchy across specialties and reflects waiting list variations Potential to extend theatre/day case capacity by extending operating hours with a new model
of medical staffing to support increased volume and range of day case and routine surgery Poor diagnostic facilities and lack of 24/7 access to some diagnostics MRI available at Ramsey for OP but not IP CT access for outpatients Mon-Fri 9-5 Expensive to upgrade existing estate Challenge of quality assurance of scans – the variation in protocols for scans across sites/out
of county mean that some scans have to be repeated Challenges in current staffing rota and recruitment Removal of training grade recognition for surgical trainees at the Horton Theatre lists sometimes cancelled because surgeon not available Limited access to specialist services at Horton, including lack of cover from JR when rota
vacancies arise Staff at Horton seen as separate from OUH – few shared posts Training and recruitment improved when workforce rotated across JR/Horton (e.g., ID,
radiology) but need for a stable workforce to ‘own’ the service at the Horton Opportunity for ‘undisturbed teaching’ to take place at Horton Difficulty maintaining 24/7 rotas and training with current skill mix/activity levels Quality and operational issues with Critical Care The Horton critical care unit takes the lowest % of ventilated admissions in the Thames Valley
network, but has the has the highest hospital mortality for ventilated admissions Delayed discharges with beds not being used for intended purpose Difficulty in recruiting with current level 3 services not sustainable if 1 more band 6 nurse was
to leave
‘open access’ diagnostics for primary and community services could create significantly increased demand for outpatients investigations
Sub-optimal service configuration Outpatient services are provided in
44 centres across Oxfordshire, with some centres not having access to diagnostics
Too many people being brought back to outpatients
Patients are brought back for follow- up in person that could be delivered over the phone / videoconference
Tariff payments fail to incentivise ‘virtual’ follow-up (significantly less than in person appointment)
Opportunity to move to a ‘nurse led’ model of follow-up with appropriate specialist back up via technology
Under-use of technology Paper notes hamper clinic efficiency
and add costs (~£50 per retrieval) Under-utilisation and lack of
flexibility of current clinic space Some specialties have dedicated
clinic space, whereas others (like surgery) don’t
No spare OP rooms for additional clinics
Lack of co-location of clinics with diagnostics – could aim for a ‘one stop service’
1
4
5
2
3
6
7
8
3131
The Horton General John Radcliffe ChurchillSpecialty
Gynae
ENT
Opthalmology
70% 77%71%
70% 82%53%
SOURCE: Trust data (April 2016)
Current state of diagnostics facility at the Horton
1 'Hot' denotes a scan that is non-elective and must therefore be reported rapidly; 2 One of these rooms doubles as a fluoroscopy room; 3 Three ultrasound machines are in radiology department, 2-3 are in maternity; 4 based on current opening hours
Radiology equipment, staff and utilisation
Staff WTE
Activity Average # of exams per machine
Utilisation Average # exams per machine per day4
Rotas are not robustly staffed in the event of sickness absence or vacancy Consultant radiologists provide services to the Horton Treatment Centre as well as the
Horton Hospital, but there are insufficient staff to do this The SpR trainee is supernumerary
Outpatient department for elective scans is open 9am-5pm Mon-Fri There is 24/7 access to urgent CTs and plain film X-rays for inpatients and A&E
All ‘hot’1 scans are reported locally All ‘cold’ scans are pooled centrally across OUH 16 multi-slice CT scanner is 10 years old and needs replacing
– Tender for new scanner was closed due to inability to agree on the best way to provide interim services whilst the new scanner was installed
The MRI scanner is located at the Horton Treatment Centre and is for outpatient activity only – inpatients are transferred to the JR for their scans as the scanner is unsafe to use in the event of a cardiac arrest
Junior doctors 1
MRI scans 3
There are opportunities to improve the current utilisation of scanning equipment but this would require additional staffing to be in place
X-rays 33
Ultrasound 12
0
10
20
30
40
50
60
70
80
90
100
Percentage of admissions (95% CI)
The Horton critical care unit takes the lowest % of ventilated admissions in the Thames Valley network …
SOURCE: ICNARC 2016
P
L F M D
SOURCE: ICNARC 2016
A M E R H B
K L N G
Delayed discharges (24 hour delay)
Unit-acquired MRSA
Delayed discharges (12 hour delay)
Out-of-hours discharges (not delayed)
Hospital mortality (risk <20%)
Hospital mortality
Non-clinical transfers (out)
Although the Horton unit performed in line with most comparators in the ICNARC audit (2013/14), it is an outlier compared to benchmarked peers for delayed discharges from critical care
There are issues with delayed discharges from critical care at the Horton site
SOURCE: ICNARC 2013/14
% of bed days utilised by critical care unit survivors with a delay to their discharge of 24 hours or more
Upper 3 SD
Lower 2SD
Horton CC
Percentage of bed days
4 ELECTIVE, DIAGNOSTIC & SPECIALIST
OUH provides outpatient services at over 40 sites across Oxfordshire and the wider health economy – some with diagnostics, some without
SOURCE: PLICS 14/15 – only sites with >100 outpatient appointments have been included
Map of locations of outpatient sites, with over 100 outpatient appointments, for OUH (2014/15)
5 ELECTIVE, DIAGNOSTIC & SPECIALIST
Contents
3838
Executive Summary - pathway improvement adult and emergency care
Adult Emergency and Urgent Care
The clinical group has a vision to – Minimize the need for patients and referrers to navigate different access points to emergency care – Improve performance on national targets for example 4hr wait and stroke care – Ambulatory diagnosis and treatment by default and increased opportunities to assess and care for
patients in their home environments – Modern staffing with increased team working and more generalist skills – Central co-ordination across the pathway
National and international evidence suggests opportunities to reduce admissions and use of A&E through better community based integrated care. There are standards nationally for timely access to senior decision making and diagnostic investigations as a result of Keogh Review into 7 day services.
Currently for The Horton General – There are 38,000 A&E attendances a year at the Horton – 6,000 of these are for patients who are
acutely unwell. Overnight, there is one attendance every two hours on average. – There are high rates of A&E attendance, emergency admission to hospital and admissions for
ambulatory care sensitive conditions across North Oxfordshire compared to the rest of the country with considerable variation from one GP practice to another .
– The current quality of care for patients suffering a stroke is very poor; while care for people with a fractured neck of femur is very good and the new surgical assessment service has reduced need to patients to travel
– Lengths of stay are long compared to the John Radcliffe and other hospitals
3939
Clinical working group proposals for Adult Urgent and Emergency Care across North Oxfordshire
ToFrom
` High use of ED Consultant led services for a wide range of conditions – Challenges of navigation across multiple different urgent
care services – Physically separated ambulatory care / EAU / A&E with
no coordinated care hub not conducive to patient flow
Integrated single ‘front door’ for patients so that they and referrers do not have to navigate the system
A‘traffic control’ system to co-ordinate the flow of patients and direct them to the most appropriate care setting (e.g., home, ambulatory care, short stay units, inpatient facilities)
Difficulties in recruitment and retention of staff Flexible staffing models that create an enhanced 24/7 ‘generalist’ capability amongst staff, so that they can manage patients who have complex comorbidities and/or are frail, supported by responsive specialist input when it adds value
High admission rates and difficulty discharging patients results in longer length of stays – Higher admission rate for ambulatory care sensitive
conditions than at the JR – Multiple blockages to discharge e.g., lack of daily senior
review at weekends, difficulty with cross-border referrals, lack of overnight social care
Care closer to home - comprehensive provision of care outside hospital, enabled by technology and point of care diagnostics (e.g., 24-7 monitoring and crisis response)
Care that is ambulatory by default enabling minimum inpatient bed use.
Undo the blockages in discharge with comprehensive provision of care outside hospital (e.g., rehabilitation at home, hospital at home)
Examples of high-performing, efficiently run services that
could be built upon – The hip fracture service is ranked 4th in the table of 180
Hospitals for achieving the NOF Best Practice Tariff
Greater provision and investment in exemplar services
4040
Access to senior and specialist skills
Standards: Summary
All emergency admissions to be seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital
The Critical Care Unit should have dedicated medical cover present in the facility 24 hours per day, 7 days per week
All hospitals admitting emergency general surgery patients should have access to an emergency theatre immediately and aspire to have an appropriately trained consultant surgeon on site within 30 minutes at any time of the day or night
Any surgery conducted at night should meet NCEPOD requirements and be under the direct supervision of a consultant surgeon
When on-take for emergency / acute medicine and surgery, a consultant and their team are to be completely freed from any other clinical duties / elective commitments that would prevent them from being immediately available
Acute medicine inpatients should be reviewed daily by a relevant consultant
Standard Keogh (2015) Transforming urgent and emergency care services in England Keogh (2013) NHS Services, Seven Days a Week
Keogh (2013) NHS Services, Seven Days a Week RCS (2011) Emergency Surgery: Standards for Unscheduled Care
Keogh (2015) Transforming urgent and emergency care services in England RCS (2011) Emergency Surgery Standards for unscheduled care NCEPOD (1997 and 2003) Who operates when?
NHS London (2011) Adult emergency services: Acute medicine and emergency general surgery commissioning standards
NCEPOD (2007) Emergency admissions: a journey in the right direction?
Keogh (2015) Transforming urgent and emergency care services in England. Note: only mentions emergency surgery
NHS England for London CCGs (2013) London Quality Standards
Keogh (2015) Transforming urgent and emergency care services in England Keogh (2013) NHS Services, Seven Days a Week. Note: Keogh recommends
twice daily consultant review for patients in high dependency areas including AMU, SAU, ICU and HDU.
Source
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Reports: Urgent Care Review aims to set a new strategic direction for emergency services, Keogh (2013)
Source: High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review End of Phase 1 Report, November 2013. Available at http://www.nhs.uk/NHSEngland/keogh- review/Documents/UECR.Ph1Report.FV.pdf
ProposalKey areas
Right advice to people with urgent care needs
Helping people with urgent care needs to get the right advice in the right place, first time – The NHS will enhance the NHS 111 service so that it becomes the smart call to make, creating a 24 hour, personalised priority contact service. This enhanced service will have knowledge about people’s medical problems, and allow them to speak directly to a nurse, doctor or other healthcare professional if that is the most appropriate way to provide the help and advice they need. It will also be able to directly book a call back from, or an appointment with, a GP or at whichever urgent or emergency care facility can best deal with the problem.
Self care Providing better support for people to self-care – The NHS will provide better and more easily accessible information about self- treatment options so that people who prefer to can avoid the need to see a healthcare professional.
Urgent care services outside of hospital
Providing highly responsive urgent care services outside of hospital so people no longer choose to queue in A&E - This will mean: putting in place faster and consistent same-day, every-day access to general practitioners, primary care and community services such as local mental health teams and community nurses to address urgent care needs; harnessing the skills, experience and accessibility of community pharmacists; developing our 999 ambulance service into a mobile urgent treatment service capable of treating more patients at scene so they don’t need to be conveyed to hospital to initiate care.
Treatment in centres with the right facilities and expertise
Ensuring that those people with more serious or life threatening emergency needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery. Once it has enhanced urgent care services outside hospital, the NHS will introduce two types of hospital emergency department with the current working titles of Emergency Centres and Major Emergency Centres. Emergency Centres will be capable of assessing and initiating treatment for all patients and safely transferring them when necessary. Major Emergency Centres will be much larger units, capable of not just assessing and initiating treatment for all patients but providing a range of highly specialist services. The NHS envisages around 40-70 Major Emergency Centres across the country. It expects the overall number of Emergency Centres – including Major Emergency Centres – carrying the red and white sign to be broadly equal to the current number of A&E departments.
Connecting urgent and emergency care services
Connecting urgent and emergency care services so the overall system becomes more than just the sum of its parts. Building on the success of major trauma networks, the NHS will develop broader emergency care networks. These will dissolve traditional boundaries between hospital and community-based services and support the free flow of information and specialist expertise. They will ensure that no contact between a clinician and a patient takes place in isolation – other specialist expertise will always be at hand.
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Reports: summary of best practice
Areas of carePathway Core referencesPrinciples
Urgent care
A&E
response teams Ambulance services
Services, NAO, 2011
GP case management for 2% risk- stratified as most vulnerable
Integrated primary care to reduce avoidable emergency admissions
Treatment at scene (or transfer to primary/community care) where appropriate
Standards for Children and Young People in Emergency Care Settings (2012)
CEM, Workforce Recommend- ations, 2010, and The Way Ahead 2008-2012, 2008
Acute and emergency care: prescribing the remedy (2014)
Triage, treatment and discharge or admission within 4 hours
Paeds triage/analgesia within 15 mins 24/7 consultant presence/decision-making 24/7 access to diagnostics and dependent
services (see next page for details) Every emergency department should
have a co-located primary care out-of hours facility
Senior decision-makers at the front door of the hospital, and in surgical, medical or paediatric assessment units, should be normal practice, not the exception
A&E
Case examples – summary (1/2) Description
Sheffield Integrated Care
City council and CCG pooled budgets to create an integrated health and social care model
Torbay and South Devon Integrated Care
Torbay and South Devon NHS Foundation Trust merged with the Adult Social Services division of the local council to create an integrated care model
ChenMed
ChenMed runs 22 “one-stop-shop” health centers Operates a full capitation model covering primary and
acute care and medicines spend, to minimise avoidable hospital admissions through intensive primary care and aligned incentives
Abingdon Community Hospital
Abingdon Emergency Multidisciplinary Unit uses an MDT ‘front door’, risk stratification and point of care testing to provide emergency care to frail and elderly
Newham Use of remote monitoring for appropriate patients to reduce the rate of avoidable hospital admissions
Impact During a 7 day pilot, 95% of patients in the
Frailty Unit were discharged within 24hrs
During pilot: – 45% more patients with care packages
within 28 days of assessment – Over-65s non-elective bed use down
by 29%; length of stay down by 19%
38% fewer hospital bed days, 18% lower hospitalisations, 17% lower readmissions
86% of specialist consultations delivered in the health center
29% improvement in medication adherence (from 44% to 73%)
30% reduction in over 80s admissions in the area over last 2 years
15% reduction in A&E visits 20% reduction in emergency admissions
CareMore Run a risk-adjusted capitation-based Medicare
Advantage plan, delivering a focused programme for 40% frailest patients with complex chronic conditions
Hospitalisation rate 24% and length of stay 38% below national averages
56% fewer CHF admissions in 3 months
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Community / Hospital / GP interface created with shared electronic records and support services e.g., rehab, pharmacy, falls management
Decreased acute admissions and LOS Use of most costly social care reduced Primary care activity increased Decreased elderly residential care spend
4444
Case examples – summary (2/2)pp yyy ((( ))) Description
Polikum group, Germany
Network of 4 composite outpatient medical care centers, using capitation payment mechanism to provide integrated care for enrolled patients
Camden frail and elderly MDT
Primary, secondary and community health MDT form a Frailty Team working across Camden
GP-led acute care, Cornwall & Isles of Scilly
GPs based in medical admissions unit at Royal Cornwall Hospital triage patients via phone system to recommend alternatives to admission
Hillingdon has a unique standalone group breathlessness clinic for patients with advanced stages of COPD
Impact Polikum executives estimated that within a
year, the company’s hospitalisation costs were reduced by about half1
Reduction in A&E attendances of almost 50% for this group of patients
On average, GPs divert 16% of attendees from A&E; have achieved as much as 50%
30% fewer emergency medical admissions
Total bed-days reduced by 9% £70,000 saved in 6 months Reduction in participants’ depression
symptoms
1 "Die Optimierer" (an interview with Wolfram Otto), McKinsey Wissen 2008
Self- management programmes, Hillingdon
Northumbria ACO12
Northumbria Specialist Emergency Care Hospital was set up in June 2015 to provide 24/7 emergency and specialist care while low acuity and planned care are provided at DGH and community hospital
Early data shows that despite increased attendances, emergency admissions have reduced since this hospital opened
Croydon Urgent & Emergency Care
13
24/7 GP-led Urgent Care Centre within A&E / integrated with the out of hours primary care; 12/7 Urgent Care Centre; Minor Injuries Unit; and NHS 111 pilot service
Evidence of improved patient care and fewer admissions
£5.22m gross saving on a recurrent basis, over three years
St. Thomas Acute Admission Unit
14 St Thomas AAU is a 7-bedded unit run entirely by
Acute Physicians that works alongside A&E to assess and treat medical patients
AAU is cheaper, requires fewer staff and has fewer admissions than their A&E with similar levels of patient care
South Somerset Symphony Programme
14 Yeovil Hospital, South Somerset GP Federation and
Somerset County Council with a single budget for primary, secondary and social care services
A&E attendances reduced by 29 % Emergency admissions reduced by 33 % LoS reduced from 10 to 5 days
4545
Clinicians’ view on the current urgent and emergency care pathway
SOURCE: Clinical interviews and team analysis
Acute setting
Front door Back door
URGENT & EMERGENCY
Too many people turning up at A&E, driven by: Confusing service configuration to
enable patients to self-direct, with no system of streaming patients, combined with fragmented out of acute hospital service provision
Variation in GP-access and out of hours access
High cost to GPs to work out of hours because of indemnity cover
Low threshold for referral from GPs in Banbury vs. Oxfordshire,
Variation in primary care provision for frail / elderly and / or people with long term conditions
‘Revolving front door’ – readmissions of chronic, complex patients
Culture of “use it or lose it” (with respect to A&E) amongst some patients and GPs
High patient expectations lead to health seeking behaviours (patients choose to come to A&E)
Deteriorating ED performance Failure to meet the 4-hour wait
consistently over the past 5 months (a Trust-wide issue)
Failure to meet the 4-hour stroke admission standard
High admission rate Higher admission rate for
ambulatory care sensitive conditions than at the JR
Slow adoption of best practices (e.g., daily board round)
Lack of credible community services that can rapidly review patients at home to avoid admission
Physically separated ambulatory care / EAU / A&E with no coordinated care hub not conducive to patient flow
Difficulty in recruitment and retention 13.25 A&E consultants (WTEs)
across 2 sites by August; no middle grades; dependency on locums
Possible (but uncertain) future need for 24/7 consultant cover
Longer length of stay at Horton Lack of daily senior review due to
insufficient staffing cover – may con- tribute to longer length of stay due to lack of discharge decision making
Specialist inputs not always immediately accessible and may not be sustainable on site - applicable along the pathway (e.g., lots of gynae patients but gynae rota unsustainable, limited access to inpatient surgical opinion, challenges with provision of critical care due to staffing and low patient numbers)
Hard to transfer surgical patients requiring specialists care at the JR (although plastics pathway work well)
Lack of inpatient MRI and out of hours US – delayed investigations prolong stay
Unsustainable inpatient volume Not enough stroke admissions to
sustain an acute stroke unit (~9/month)
Examples of good practice #NOF outcomes Success of surgical assessment unit
Not enough people being discharged Variation in discharge
threshold across the whole MDT
Delayed transfers of cares block up medical wards due to waiting time for care package from social services or lack of appropriate rehab support (e.g., step down beds)
No overnight or ‘short notice’ social care, com- pounded by a national shortage of carers
Difficulty in discharging cross-border patients, with no clear account- ability for these patients
Fragmented community services, making it difficult to refer to them
No ‘hospital at home’ that can be deployed rapidly
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3
6
1
4
5
8
7
4646
Considerable variation in patient satisfaction with GP access and out-of-hours services
10080604020
-47%
SOURCE: GP patient survey January 2016; July 2015
1 Horton catchment and 13 other Oxfordshire GP practices did not report findings for out of hours services
Good experience in booking appointment % patients, 2015
Ease in contacting out of hours GP by telephone1
% patients, 2014/2015 Satisfied with opening hours % patients, 2015
Confidence and trust in out of hours clinicians1
% patients, 2014/2015
% of patients seen, treated and admitted/discharged within 4 hours A&E 4-hour wait performance at the Horton and JR vs. England average
Month achieved 95% targetMonth failed 95% target Trust’s quarterly average performance
Horton
JR
2013/14 2014/15 2015/16
SOURCE: Client data, and NHS England statistics for National performance
2 URGENT & EMERGENCY
Stroke 4 hour admission split by site (85%v threshold)
Percent
The Horton performs poorly on access targets for stroke care
73.3
The Horton Hospital performs poorly in the national audit for stroke care
SOURCE: SSNAP audit 2014/15
Quality Account Abstract This report is based upon patients arriving at the Horton Hospital (or having stroke onset as an inpatient) primarily between 1 April 2014 – 31 March 2015 and patients who were discharged from inpatient care during the same period.
The SSNAP score is calculated from Key Indicator scores which are grouped into 10 domains
Domain 1 Scanning D
Domain 3 Thrombolysis E
Domain 6 Physiotherapy D
Domain 8 Multidisciplinary team working D
Domain 9 Standards by discharge C
Domain 10 Discharge processes C
Overall SSNAP level (SSNAP score 32.4)
E
Benchmarked against all UK sites according to quartiles of performance
A: top quartile
B: second quartile
Out of Hours A&E attendance is higher for Horton catchment GPs
0
50
100
150
200
250
Direct age-sex Standardised Rate per 1,000, April 2014 - March 2015
Oxford City WOLG North East NOLG South East South West Linear (CCG Average)
*A&E Attendances at Type 1 Depts only Source: SUS Data as at March 2015 Population Data: Exeter April 2015 L uther Street excluded due to low population
Horton catchment area represented by NOLG (North Oxfordshire Locality Group)
5151
In hours A&E attendance is higher for Horton catchment GPs
0
20
40
60
80
100
120
140
160
180
Direct age-sex Standardised Rate per 1,000, April 2014 - March 2015
Oxford City WOLG North East NOLG
South East South West Linear (CCG Average)
*A&E Attendances at Type 1 Depts only Source: SUS Data as at March 2015 Population Data: HSCIC April 2015 L uther Street excluded due to low population
Horton catchment area represented by NOLG (North Oxfordshire Locality Group)
5252
Ambulatory care sensitive (ACS) admissions for over 65 population is 5% higher among Horton catchment area GP practices
20
77
SOURCE: HES 2014/15; Public Health England General Practice Profiles 2015
ACS admissions in people aged 65+ in Horton catchment GP practices vs. the rest of Oxfordshire Per 1000 people aged 65+, 2014/15
Horton catchment area
Emergency admission rates for people over the age of 65 are higher with the GP practices in the Horton catchment area
338
SOURCE: HES 2014/15; Public Health England General Practice Profiles 2015
Non-elective admissions aged 65+ in Horton catchment GP practices vs. the rest of Oxfordshire Per 1000 people aged 65+, 2014/15
Horton catchment area
Rest of Oxfordshire
The % of bed days occupied by delayed discharges is higher at the Horton than JR
URGENT & EMERGENCY
145 11,908 3,324 28%
% of bed days delayed
633 51,985 6,453 12%JR
Delayed bed days as a percentage of overall bed days for the first 3 months of 2016
SOURCE: Trust data
5555
The hip fracture service at the Horton is the 4th best in England and uses KPIs to drive improvements in care
SOURCE: #NOF KPIs February 2016
cement time recorded blood loss recorded recovery Hb check
MDT fit for discharge within 7 days delirium free so far
no post op AKI sat out within 24 hours post op
post op AMTS post op review within 24 hrs
halfhourly obs for 4hrs post op episode on HDU
BPT achieved NICE compliant op
op within 48 hrs op within 36 hrs op within 24 hrs
Consultant Surgeon present in… Consultant Physician review…
Consultant Geriatrician review… ASA score recorded
A/E discharge within 4 hours Xray within 1 hour
pre op AMTS pre op DNR decision
admission VTE assessment pre-op hip block
Repose mattress within 4 hrs IVI within 4 hrs
IV paracetamol within 4 hrs
number of patients
yes
no
The hip fracture service is ranked 4th in the table of 180 Hospitals for achieving fractured NOF Best Practice Tariff
88% of all patients achieved all nine Best Practice Tariff requirements (national average 63.3%)
5656
Emergency surgical assessment unit at the Horton site has reduced the burden for assessment at the JL site
SOURCE: OUH community network partnership update (2015)
The availability of consultant specialist opinion on a 24x7 basis at the Surgical Emergency Unit at the John Radcliffe, together with other enhancements of the emergency surgery referral pathway, have helped to achieve this reduction
From the beginning of 2015/16 ”video” consultations will also be available to staff at the Horton, further strengthening the patient pathway
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Nov
Dec
July
June
Sep
Aug
April
May
March
Oct
URGENT & EMERGENCY
Reports: summary of best practice
Areas of carePathway Core referencesPrinciples
Urgent care
A&E
response teams Ambulance services
Services, NAO, 2011
GP case management for 2% risk- stratified as most vulnerable
Integrated primary care to reduce avoidable emergency admissions
Treatment at scene (or transfer to primary/community care) where appropriate
Standards for Children and Young People in Emergency Care Settings (2012)
CEM, Workforce Recommend- ations, 2010, and The Way Ahead 2008-2012, 2008
Acute and emergency care: prescribing the remedy (2014)
Triage, treatment and discharge or admission within 4 hours
Paeds triage/analgesia within 15 mins 24/7 consultant presence/decision-making 24/7 access to diagnostics and dependent
services (see next page for details) Every emergency department should
have a co-located primary care out-of hours facility
Senior decision-makers at the front door of the hospital, and in surgical, medical or paediatric assessment units, should be normal practice, not the exception
A&E
Contents
5959
Executive Summary - pathway improvement maternity care
The clinical group in collaboration with the STP workstream has a vision for maternity care across Oxfordshire where – Equity of access to the same high quality standard of maternity care across the whole of Oxfordshire – Early booking with effective early risk assessment, therefore enabling informed choice but real choice of
birth location – The right woman, into the right part of the service and cared for by the right professional with sustained
continuity of care (not necessarily carer) – Offer real choice to women by creating services that match demand – A service where staff want to work, which offers new career development opportunities and time for
teaching and research – Optimise the use of existing resources including reconsidering the staffing model across sites
This vision is consistent with the outcomes of the recent national review into Maternity services and the recommendations from NHS England resulting from that
Currently – The current provision of obstetric services across North Oxfordshire is highly fragmented with three
midwife led units (vary from 1 to 3 births a week), a small lower risk unit at Horton (~4 births a day) and a full service unit at the John Radcliffe (~15 births a day). This is highly inefficient as staff need to be present 24 hours a day.
– Quality of care at the Horton is not as good as it could be though patient satisfaction is higher than at the John Radcliffe
– It has been challenging to attract and retain staff at The Horton General however recent rotations of midwife staff between units has been beneficial to staff satisfaction and skills
6060
Clinical working group proposals for Maternity Care
Offer real choice to women by creating services that match demand
Choice available but underutilised services in some areas – Mismatch in location of MLUs and patients who
use them
Equity of access to the same high quality standard of maternity care across the whole of Oxfordshire
Early booking with effective early risk assessment, therefore enabling informed choice but real choice of birth location
The right woman, into the right part of the service and cared for by the right professional with sustained continuity of care (not necessarily carer)
Variations in antenatal service provision and knowledge across Oxfordshire – Method of risk assessing women in pregnancy not being
done in a consistent manner – Women's choice of care heavily influenced by who they
meet and individual needs Variations in the quality of intra-partum care across
Oxfordshire with an increased need for ambulance transfers
An opportunity to provide care closer to home for many women – Some women are brought to hospital clinics for care that
could be delivered in the community – No handheld electronic maternity record, CTG assessment
or scanning in the community
Provision of care in the community where clinically appropriate, with uniform IT systems and mobile technology as a key enabler
Difficulties with recruitment and retention of staff (particularly more senior staff) – Not enough consultants to provide 168hr cover at the JR
(recommended by RCOG for units with high complexity case load and >5000 deliveries)
– Lack of training recognition at the Horton creates a reliance on locums
– Context of national shortages of obstetric & gynaecology trainees
A service where staff want to work, which offers new career development opportunities and time for teaching and research
Optimise the use of existing resources including reconsidering the staffing model across sites
ToFrom
6161
No. Personalised care1
Continuity of carer2
Maternity survey e-referral data
1.1 Every woman should develop a personalized care plan, with their midwife and other health professionals, which sets out her decisions about her care, reflects her wider health needs and is kept up to date as her pregnancy progresses and after the birth
Providers and CGGs 100% of women by 2020
Maternity survey and NIB monitoring
1.2 Unbiased information should be made available to all women to help them make their decisions and develop their care plan drawing on the latest evidence, and assessment of their individual needs, and what services are available locally. This should be through their digital maternity tool
National Information Board (NIB) and NHS England
By April 2017
Maternity survey, e-referral data and CCG Assessment
1.3 Women should be able to choose the provider of their antenatal, intrapartum and postnatal care and be in control of exercising those choices through their own NHS Personal Maternity Care Budget
NHS England and CCGs Pioneer sites in 2016/17. Potential full roll out from 2017/18
Maternity survey, e-referral data and CCG Assessment
1.4 Women should be able to make decisions about the support they need during birth and where they would prefer to give birth, whether this is at home, in a midwifery unit or in an obstetric unit after full discussion of the benefits and risks associated with each option
CCGs Most women should have access to 3 types of birthplace by 2020
Maternity survey2.1 Every woman should have a midwife, who is part of a small team of 4 to 6 midwives based in the community who know the women and family, and can provide continuity throughout the pregnancy, birth and postnatally
Providers and CCGs Early adopters to roll out from 2016/17. Across the country by 2020
Staff feedback2.2 Each team of midwives should have an identified obstetrician who can get to know and understand their service and can advise on issues as appropriate
Providers and CCGs By 2020
CCG Assessment2.3 Community hubs should enable them to access care in the community from their midwife and from a range of others services, particularly for antenatal and postnatal care
NHS England – national support and guidance CCGs and providers – local implementation
Plans for community hubs to be in place and agreed by end 2016/17, for roll out by 2020
Maternity survey, Local Maternity System governance
2.4 The woman’s midwife should liaise closely with obstetric, neonatal and other services ensuring that they get the care they need and that it is joined up with the care they are receiving in the community
Providers From now
3.1 Provider organization boards should designate a board member as the board level lead for maternity services. The Board should routinely monitor Information about quality, including safety and take necessary action to improve quality
Providers By 1 April 2016/17 CQC inspections
3.2 Boards should promote a culture of learning and continuous improvement to maximise quality and outcomes from their services, including multi- professional training. CQC should consider these issues during inspections
Providers and CQC From 2016/17 CQC inspections
6262
National Maternity Review. Better births. NHS England recommendations (2/3)
3.3 There should be rapid referral protocols in place between professionals and across organisations to ensure that the woman and her baby can access more specialist care when they need it
Providers and CCG Timetable to coincide with establishment of local maternity systems. Full roll out by end 2018/19
Local maternity system governance
3.4 Teams should collect data on the quality and outcomes of their services routinely, to measure their own performance and to benchmark against others to Improve the quality and outcomes of their services
Providers and regional networks From 1 April 2017 following publication of national guidance
Regional clinical network monitoring, CQC inspections
3.5 There should be a national standardised investigation process when things go wrong. to gel to the bottom of what went wrong and why and how future services can be improved as a consequence
Health Care Safety lnvestigation Branch, NHS Improvement, Maternity Clinical Networks
By end 2016/17 OH/ NHS Improvement/ HCSIB monitoring
3.6 There Is already an expectation of openness and honesty between professionals and families, which should be supported by a rapid redress and resolution scheme, encouraging rapid learning and to ensure that families receive the help they need quickly
DH and NHS Litigation Authority By 2020 OH Implementation
4 Better postnatal and perinatal mental health care
4.1 There should be significant investment in perinatal mental health services in the community and in specialist care
Mental Health Implementation Board. NHS England and CCGs
By 2020 CCG Assessment Framework, Mental Health Minimum Dataset (MHMDS), MCMDS
4.2 Postnatal care must be resourced appropriately. Women should have access to their midwife as they require after having had their baby
CCGs and providers By end 2018/19 Maternity survey, MCMDS
4.3 Maternity services should ensure smooth transition between midwife and obstetric and neonatal care, and when appropriate to ongoing care in the community from their GP and health visitor
CCGs and providers By end 2016/17 Maternity survey
4.4 A dedicated review of neonatal services should be taken forward in light of the findings of this review
NHS England By end 2016/17 NHS England reporting
5 Multi-professional working 5.1 Those who work together should train together. The Nursing and Midwifery Council
and the Royal College of Obstetricians and Gynaecologists should review education to ensure that it promotes multi-professionalism and that there are shared elements where practical and sensible
NMC, RCOG Review to be complete by end 2016/17 NMC & RCOG to include in their education from now and from Sept 2017 at the latest
NMC and RCOG reporting
No. How will we know?Recommendation/action Owners Timeframe/ scale of ambition
5.2 Multi-professional training should be a standard part of professionals’ continuous professional development, both in routine situations in emergencies
NHS England, HEE, RCM, RCOG, employers
DH and HEE fund post- registration training in 2016/17 thereafter responsibility of employers
HEE reporting CQC inspection Board reporting
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National Maternity Review. Better births. NHS England recommendations (3/3)
5.3 Use of electronic maternity records should be rolled out nationally, to support sharing of data and information between professionals, organisations and with the woman. Commissioners and providers should invest in the right software equipment and infrastructure to collect data and share information
NHS England, providers By 2020 Digital Maturity Self- Assessment will cover electronic records generally
5.4 A nationally agreed set of indicators should be developed to the local maternity systems to track, benchmark and improve the quality of maternity services. This should include the possible development of PROMS/PREMs measures for maternity
NHS England, RCM, RCOG Convene by Spring 2016, report by end 2016/17
NHS England reporting
5.5 Multi-professional peer review of services should be available to support and spread learning. Providers should actively seek out this support to help them improve, and they must release their staff to be part of these reviews. CQC should consider the issue as part of inspections
RCOG and RCM to provide support, employers to release professionals
By end 2017/18 RCM and RCOG repor-ting CQC Inspection
6 Working across boundaries 6.1 Providers and commissioners should come together in local maternity systems
covering populations of 500,000 to 1.5 million, with shared standards and protocols agreed by all
NHS England - national support and guidance; CCGs and providers- local implementation
Planning for working In this way 2016/17; begin to work in this way from 2017/18. Full roll out by end 2020
CCG Assessment
6.2 Professionals, providers and commissioners should come together on a larger geographical area through Clinical Networks, coterminous for both maternity and neonatal services, to share Information, best practice and learning, to provide support and to advise about the commissioning of specialist services which support local maternity systems
NHS England national and regional funding and support; CCGs and providers are members
From now NHS England assurance of Clinical Networks
6.3 Commissioners should take greater responsibility for improving outcomes, by commissioning against clear outcome measures, empowering providers to make service improvements and monitoring progress regularly
CCGs From now — with demonstrable progress by end 2020/2021
CCG Assessment
6.4 NHS England should seek volunteer localities to act as early adopter sites NHS England A two year programme to start in September 2016
NHS England reporting
7 Payment system
7.1 The payment system for maternity services should be reformed. In particular, it should take into account: • The different cost structures different services have, i.e., a large proportion of
the costs of obstetric units are fixed because they need to be available 24 hours day, seven days a week regardless of the volume of services they provide
• The need to ensure that the money follows the woman and her baby as far as possible, so as to ensure womens choices drive the flow of money, whilst supporting organisations to work together
• The need to incentivise the delivery of high quality and efficient care for all women, regardless of where they live or their health needs
• The challenges of providing sustainable services in certain remote & rural areas
NHS England and NHS improvement
Develop proposals for reforming payment system 2018/17; pilot new system 2017/18; Implement new system 2018/19
NHS England and NHS Improvement reporting
No. How will we know?Recommendation/action Owners Timeframe/ scale of ambition
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SOURCE: Clinical pathway group meeting and team analysis
Clinical working group assessment of the current maternity pathway Acute setting Out of acute setting(s)
Ante-natal care Post-natal care
Front door Back door
Variations in antenatal care There are inequalities of antenatal service provision and knowledge across Oxfordshire, with some barriers to working between acute and community care
Method of risk assessing women in pregnancy not being done in a consistent manner
Women's choice of care heavily influenced by who they meet and individual needs
No systems of identification for women ‘at risk’ of mental health during pregnancy
Cost of family nurse partnership is high and should be reviewed
Gynaecology input for early pregnancy is part of this pathway
More can be done via technology to keep care closer to home and provide reassurance for women
Some women are brought to ante-natal clinic for care that could be delivered in the community
No handheld electronic maternity record, CTG assessment or scanning in the community
Different IT systems hamper information sharing between hospital and community
Post natal care is catered to most, but not all, women
Lack of services for ‘career‘ women who are >35yrs who are often isolated
Inequity of access to postnatal care
Routine post-natal women are having to travel to hospital for follow-up, when this could be delivered closer to home
Some women readmitted for neonatal rather than maternal issues
Loss of children's centres will impact delivery of local antenatal/postnatal clinics
There should be more postnatal care, rather than less
Asymmetry of mental health services available for pregnant and post-natal women
Mental health services available in lots of different settings (OUH, Oxford Health, GP)
Across Oxfordshire, the provision of intra-partum care is not aligned with the needs 3 community SMLUs are not located where pregnant women currently live, nor where they
are likely to live in future Increasingly complex patients who require obstetrician led units with sub-specialty expertise,
co-located with ITU, medical and surgical support – having 2 of these units for a population of ~650K people may not be clinically or financially viable
Risk of losing patients North of the border (may choose to give birth elsewhere) Current provision of services across Oxfordshire is potentially not clinically sustainable ~5,700 births at JR (~4000 (75%) delivered by 10 WTE obstetricians), ~1,500 births at
Horton ( ~400 (33%) delivered by 5 obstetricians) and ~390 births across the 3 SMLUs
Several incidences at the Horton where the unit were having to be closed as no locums available
Lack of training recognition with a hybrid-model of mid-grade clinical research fellow posts (splitting time between clinical work and research) likely to end at Horton
Difficulty in recruitment and retention of workforce Due to decreased workload, consultants at Horton feel de-skilled Lack of consultant input at Horton has impacted on quality of teaching at Horton National shortage of obs & gynae medical trainees reflected locally (not enough applicants to fill posts) Difficulty in retaining experienced staff High cost of living in Oxford leads to difficulties retaining workforce
Inequity of provision of perinatal mental health care at the Horton and JR Women who require specialist maternity psychological medicine input have to travel to the JR as there is no dedicated maternal mental health team at the Horton
Some quality / outcome measures for inpatient maternity services could be improved Lack of clinical support services at Horton has increased need for ambulance transfers to JR Withdrawal of ability to investigate PE/DVT means patients are transferred to JR Lack of inpatient MRI means patients are transferred to JR Withdrawal of emergency general surgery leads to transfers to JR for procedures like EVAC
Limited physical space and time in partners facilities
1
2
MATERNITY
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There are 2 obstetrician led maternity units and 3 community MLUs delivering a total 7,450 births in 2014/15 across Oxfordshire
1,394 1,397
Chipping Norton Hospital Unit (MLU)
61 118
206 112
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SOURCE: HES 2013/14 and 2014/15; HSCIC Maternity activity; Trust data (home births) 14/15
1 MATERNITY
172 home births across Oxfordshire
36 of which were in Banbury
6666
In spite of the Horton site delivering more normal births, it performs below JR level on a number of quality indicators
13% 17%
7% 9%
6% 4%
1.5% 1.3%
9% 7%
84% 79%
0.6% 0.5%
64% 60%
12% 13%
10% 11%
70% 62%
11% 14% 14% 15%
SOURCE: HES For Horton and JR – provided by client. Cumulative for 11 months of 2015/16; for national benchmarks: Maternity Statistics 2014/15 and Maternity CQC Patient Survey, 2013
81% 74%
Haemorrhage (Massive PPH>2L)
% of elective s-sections
National average
2 MATERNITY
Patient satisfaction at the Horton site is slightly higher compared to JR and peer Trusts1
SOURCE: Maternity Friends and Family Test (FFT) Data - March 2016
Birth Percent
97
91
100
98
98
97
96
96
99
96
GST
JR
UHB
Barts
Imperial
CMUH
Lancashire
UCLH
Horton
97%
92
94
92
98
94
92
87
92
95
82
91%
NOTE: Trust peer group selection is described in the Appendix 1 Average for all Trusts and Health Boards with neonatal surgical provision and a level 3 NICU. Imperial, Lancashire and Royal Free belong to other
comparator groups (MBBRACE rating is for appropriate comparator).
MATERNITY
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Contents
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Executive Summary - pathway improvement paediatrics
The clinical group in collaboration has a vision that includes – Even more seamless integration across care settings and organisational boundaries using the Imperial
Child Health Hub as an exemplar model for shared care – Help support parents to rapidly access services when needed – Children cared for in optimal setting of care (home), and if admission is necessary, aim for children to
stay in hospital for as short a time as possible – Care that is proactive and empowers children and families to manage at home, by working with parents,
schools and the third sector to promote health and address parental concerns – Upskill staff by using multidisciplinary expertise to deliver this care. – Aspire to employ and develop a workforce who have a great “experience” of working for children in
Oxfordshire – Optimise the use of existing resources including reconsidering the distribution of case mix across sites
This vision was informed by The Nuffield Trust report on new models of child health services and a reviewed of the latest standards published by the Royal College of Paediatricians
Currently – Rates of emergency admissions for children at the Horton (around 11 a day) are higher than at the John
Radcliffe but nearly 75% of children stay in for less than a day – There are 12 consultation pediatricians at the Horton required to maintain cover for the (~2000 inpatient
spells per year). There are no training posts for junior doctors at the Horton. This compares to 10 paediatricians at the JR (~16,000 inpatient spells per year)
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Clinicians’ proposals for Paediatric Care
Even more seamless integration across care settings and organisational boundaries using the Imperial Child Health Hub as an exemplar model for shared care
Help support parents to rapidly access services when needed
Examples of successful pathways that are already breaking down boundaries between acute and community care – Close working relationships between Oxfordshire
providers (e.g., OUH and Oxford Health’s joint autism assessment pathway)
High referral rates and A&E attendances – Higher GP referral rate in Horton catchment area – Some avoidable A&E attendances – 50% of paediatric
A&E episodes at Horton are for minor injuries and illnesses
Children cared for in optimal setting of care (home), and if admission is necessary, aim for children to stay in hospital for as short a time as possible
Care that is proactive and empowers children and families to manage at home, by working with parents, schools and the third sector to promote health and address parental concerns
Difficulties with recruitment and retention of staff (particularly senior nursing staff)
Upskill staff by using multidisciplinary expertise to deliver this care.
Aspire to employ and develop a workforce who have a great “experience” of working for children in Oxfordshire
Inequity of resource provision across the service – Lack of paediatric training recognition at the Horton leads
to a 24/7 consultant staffed service, whilst the JR is unable to deliver 24/7 consultant-led care
– High demand for beds at the JR whilst there is a lower demand for beds at the Horton (especially in summer)
Optimise the use of existing resources including reconsidering the distribution of case mix across sites
ToFrom
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Child health is evolving to become more patient-centred with improved access to connected services in order to improve health outcomes
Potential interventions
SOURCE: Nuffield Trust The future of child health services: new models of care
Context
UK-wide, Children are 20% of the population but 40% of GP work
40-50% of GPs have had little or no formal paediatric training
Subsequently, more children are referred and admitted to hospital while ~25% of A&E presentations are children
Current organisation of child health services:
What 12 models of care are trying to address
Pr im
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C om
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Po pu
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Understand children, young people and their families’ specific needs (including broader determinants)
Enable access to high-quality pediatric