Learning from the Experience of Service Centralisation in Leeds

1. Learning from the Experience of Service Centralisation in Leeds Dr Greg Reynolds Consultant Cardiologist Clinical Director Cardiology and Respiratory Medicine

2. First consultant appointment 1996, ST14 • College tutor for 4 years (36 SHOs) • Cardiology Training Program Director (31 SpRs) Leeds and Hull based trainees • On call for Cardiology and for Acute Medicine 1:7 • Clinical Director for Cardiology (+Respiratory Medicine) since 2004 • Senior Clinical Leader role (SHA) Darzi • Choose and Book lead (SHA) • Joint chair Cardiology Redesign group (from old Long-term Conditions pathway group) NHS Leeds • Joint chair Public Health steering group NHS Leeds

3. Reflection: I am quite good at spending other people’s money • Management style is by agreement • Community Heart Failure project 2003 £500K PCT expenditure on heart failure service • Cited by Leeds PCT as an example of good practice • Public Health £500K community service development 2010 NHS Leeds, website LeedsLetsChange • Cardiac redesign 2011, NHS Leeds commissioned blood testing program (BNP) £120K pa against future savings from the Acute Trust

4. Leeds Hospitals • Leeds population 850,000 • Two main teaching Hospitals • Leeds General Infirmary (LGI) older, traditional, central Leeds, close to shops and restaurants • St James Hospital built on site of Victorian workhouse, huge bed base, poorer part of the city (LGI expensive cars an opportunity)

5. United Leeds Teaching Hospitals • The two Trusts merged in April 1998 to become the largest single Hospital Trust in the UK • We all agree we are now one organisation • But of course St James (LGI) is better than LGI (St James) and always will be

6. United Leeds Teaching Hospitals • This was a merger of Chief Execs and the Trust boards in April 1998 • In practice the name on the stationery changed but little direct effect on services • Most services still available on both sites • Became “Leeds Teaching Hospitals”

7. Reflection on Trust merger • Scottish independence ? • Hostile takeover ? • Slap in the face with a wet fish ?

8. Jubilee Building • Opened in late1998 • New building cost £90 million • Yorkshire Heart Centre built on the LGI site (+ neurosurgery) • In retrospect built on the wrong site

9. Cardiology centralisation • A Cardiologist from LGI and a Respiratory Physician from St James were chatting in their local pub (Oct 2005) • Wouldn’t it be a good idea if my service centralised on my site….. • And most people agreed this would be a good idea • If the idea is right don't let existing cultures and prejudices dictate strategy

10. Achieving Clinical Engagement

11. LGI “Yorkshire Heart Centre” 14 Cardiologists 3 Respiratory physicians 74 Cardiology beds St James 5 Cardiologists 6 Respiratory Physicians 56 Cardiology beds Achieving Clinical Engagement

12. SJUH Consultants view • But of course St James is better than LGI and always will be 5 consultants • My predecessor as Clinical Director • Professor of Cardiology • 3 very competent clinical cardiologists • This was an entirely competent clinical service

13. Why change ? • The Trust Board say that patient safety comes first, but we all know that they only reward meeting targets which allow (us) to achieve Foundation Trust status • Was this simply a cost saving exercise ?

14. SJUH Consultants view • Following a series of meetings 4 consultants accepted the rationale for change and were in agreement to work to achieve the goals of the organisation • One did not. A compromise solution was agreed with the Medical Director. The consultant has since retired.

15. Achieving Clinical Engagement • Not everyone will agree, need opinion leaders on board* • Some solutions need high level external pressure (*The recent clinical engagement day I attended said you need complete agreement on why change is needed….)

16. Planning service change

17. Planning service change • 130 Cardiology beds cross-site became 100 beds on a single site • Immediate staff concern regarding loss of employment • Continued to provide clinics and a non-invasive service at St James only

18. Staff groups • Doctors Intricacies of reorganising junior doctor rotas. More SpRs, less FY1s and SHOs • Nurses Closed one ward on each site with nursing redeployment very effectively supported by matrons • Technicians Agenda for change had recently caused major disruption, no additional losses

19. Timetable First discussed Oct 2005 First meetings Jan 2006 Ward moves Sep 2006 • Planning groups, key players including Ambulance service • Consultant integration was easier to achieve than nursing integration

20. Planning service change • Staff have a high degree of loyalty to the institutions in which they work and do not welcome change • Once the “tipping point” of accepting the inevitable was reached it became a straightforward planning process • We fully committed to the strategy

21. The year that followed…

22. The year that followed…. • We overprovided on the site that was losing the service A cardiologist was timetabled to spend their full day cross-site (Mon-Fri) A cardiology SpR was timetabled to spend their full day cross-site (7 days) • Initially the transferred Cardiology ward was in a separate block in old accommodation. This was a disaster requiring to be changed rapidly

23. The year that followed • Benefits: £3million immediate annual cost saving on a budget of £45 million. • Services delivered efficiently with economies of scale • Consultants able to achieve sub specialist ambitions • Our average length of stay is 5.5 days compared to 6.5 days for peers

24. None of the consultants would go back to how it was before • Managers see this as a successful merger • My ward sister preferred her previous ward but only since becoming a female ward

25. The year that followed… • Cost savings achieved, quality maintained and increased efficiency achieved

26. Other Service Centralisations • Following on from this many further reorganisations have occurred in Leeds • For 10 years a new Children’s Hospital was projected. • Leeds has struggled for years to balance the books • At a cost of £300 million this was deemed unaffordable

27. A Children’s Hospital was achieved by reconfiguring services in existing accommodation • A major issue for the Children’s Hospital has been that obstetric services are on a different site requiring the provision of 2 Paediatric ICUs

28. Orthopedic services have been split into elective services on a non-acute site and acute services in the Jubilee Building (Yorkshire Heart Centre) with a view to becoming a designated Trauma Centre

29. Medicine Centralisation • Leeds has always struggled to achieve 4 hour access targets • The success of Respiratory / Cardiology centralisation was followed in Medicine division by centralisation of Acute Medicine and Elderly Medicine at St James • Same targets: economies of scale, cost saving, quality and efficiency

30. Medicine Centralisation • Medicine centralised in Jan/Feb • Elderly Medicine in December • Complete withdrawal of services from LGI site, no RMO cover, Failed to look at organisational need, too focussed on local service need • Continuing bed crises • Some care of elderly services housed in old remote accommodation with issues about care standards • Lack of leadership: Insufficient Acute Medicine physicians to lead the service

31. Medicine Centralisation • Not able to fully integrate neurology and acute stroke services on alternative site • Don't have the critical mass to deliver HASU (hyper acute stroke unit)

32. (Medicine) Centralisation • Some services (Medicine, Stroke, Children’s services) have struggled because of split site services • Personal view: It would work better if all services were on one site, if it was affordable I would close my hospital and move to the workhouse site

33. Finally, Regional Cardiology services and acrimony • Since 2006 the gold standard treatment for heart attack is an urgent angiogram and coronary stent (PPCI) • This requires a consultant cardiologist and cathlab team to be available acutely 24 hours a day • Leeds PPCI service covers Leeds, Bradford, York, Harrogate, Airedale, Wakefield, Dewsbury and Pontefract • Air ambulance • 1000+ cases per year • Population ~ 2.5 million • Leeds has 7 specialist consultants

34. Regional Cardiology • Agreed that 8 LGI based consultants and 8-12 DGH based consultants would provide the service • Accommodation suggested that Leeds would pay hotel costs for DGH consultants, agreed to an on call room • Issue of fitness to work the next day and compensatory rest payment to the Trust • Total cost for consultant on call reckoned by DGH participants at £1.2 million pa

35. Regional Cardiology rota • After a series of meetings we invited the Leeds Deputy Medical Director with responsibility for medical workforce issues to address the group • He was verbally abused and no conclusion reached

36. Regional Cardiology rota • We invited the Medical Director of the SHA to chair the next meeting • General level of tension lessened • After a couple more meetings agreement was reached with the DGH employing Trusts with terms and conditions that were mutually acceptable

37. Regional Cardiology rota • It is now all sweetness and light • Some solutions need high level external pressure • It’s not personal

38. Conclusions • Service centralisation can bring clear benefits • Staff have a high level of loyalty to their institution • Cross site working is challenging because of the interdependencies of different services • Senior Medical engagement is absolutely necessary • Some solutions need high level external pressure from within or without the organisation

39. Conclusion • It’s not personal (usually) • Thank you