London and South East England Specialised Burns Project

1. London and South East EnglandSpecialised Burns Project Stakeholder engagement event 20th July 2011 The Hilton Hotel, Gatwick

2. London and South East EnglandSpecialised Burns Project Welcome and introductions Robert Creighton Senior Responsible Officer, London and South East England Specialised Burns Project Former Chief Executive, Ealing, Hillingdon and Hounslow PCTs Transitional Director, London Public Health

3. This work is led by the London Specialised Commissioning Group on behalf of the Specialised Commissioning Groups in London and South East England. • The project is being delivered by London Health Programmes. • The project’s purpose is to: • establish and sustain high quality burn services, delivering best practice and meeting all appropriate national standards of care. • deliver equitable access for the population in London and South East England. • use the available financial resources effectively and efficiently. • The outcome of the review of specialised burns services is intended to • ensure the sustainable and optimal delivery across London and South East England. Introduction

4. This event is intended to provide key stakeholders with: • An overview and update on the project’s work to date. • The opportunity to provide feedback and comment on the case for change. • The opportunity to contribute to the development of the model of care. • The audience: • Invitations to attend today’s stakeholder event were sent a wide range of • NHS organisations, patient groups and charities in London and South East • England including: • All Acute Hospital Trusts • Ambulance services • Royal Colleges (Paediatrics and Child Health, Nursing, Anaesthetists) • Providers of specialised burn services • SHAs and SCGs. Stakeholders

5. Provide feedback and comments on the draft case for change. • Contribute to the development of a model of care for specialised burn services in London and South East England. Objectives of the day

6. London and South East EnglandSpecialised Burns Project The patient perspective Henrietta Spalding Patient and Public engagement lead, London and South East England Specialised Burns Project Head of Policy and Practice, Changing Faces

7. Patient engagement forms an integral part of this case for change. • It is important to ensure that the patient voice is represented when considering how services could be improved. • It is not possible to identify how services can be improved without seeking input from those with direct experience. Why engage with patients?

8. The project has sought the views of patients and their families / carers on • their experiences of specialised burns services, in a variety of ways • including: • Two dedicated patient stakeholder events – one in London and one in Aylesbury. • Facilitated workshops at stakeholder events. • One to one focussed interviews led by Changing Faces. • All of the feedback received has been used to inform the development of • the case for change. Patient engagement activity to date

9. Feedback received at each event was generally consistent with a number of key themes: • The importance of equitable clinical care. • Support for, and the role of, carers and family members. • The importance of psychological support. • The importance of communication and information. • The importance of relationships with staff. • The challenges of transition of care from child to adult services. • Referrals, accessibility and system gaps. • Variable discharge and availability of aftercare. Key themes arising from patient feedback

10. These are some extracts from patients, commenting on their experiences of specialised burn services in London and South East England “Aftercare is a bit hit and miss” and “[there is] a “big gulf between hospital and home.” “Carers [and patients] have to be assertive to get the help they need.” “Knowing that there was a specialist team was really reassuring – we just assumed that she would be treated at her local hospital.” What did patients say? “Support with the way I look was poor. I had been an inpatient for a long time and although I had access to a psychologist, what I needed was someone who could take me out (into society) step by step, just for a coffee or to do some shopping, to make it easier.” “The options available were excellent… I was consulted on [the] different types of painkillers available” “I really can’t praise the staff enough – you build relationships with them and start to get to know them.” “Going onto the adult’s ward was like ‘starting again’ .” “There was always someone on hand to provide help or information.” “The referral system seems to be quite complicated and difficult to navigate.”

11. Allied Health professionals Nurse Social Care Patient centred care Burn Surgeon Other specialities Psychological therapist GP & Primary Care

12. Feedback received during the development of the case for change is presented in full in Specialised burns services project: Patient engagement and feedback summary report. • Feedback received from patients highlights that there are differences in the care provided at current services and that there remain areas for improvement. • There was an overwhelming feeling from patients that co-ordination of care, links with other agencies and effective MDT working were very important. • We are committed to continuing to engage with patients throughout this process. • Further stakeholder engagement activities will be planned during each phase of the project, to ensure that patients’ needs and views are considered and incorporated into recommendations made. Summary and findings

13. London and South East EnglandSpecialised Burns Project The case for change Ken Dunn Chair of the Clinical Expert Panel, London and South East England, Specialised Burns Project Consultant Plastic Surgeon, University Hospital South Manchester

14. National Burns Care Review (NBCR) and injury referral guidelines • published • National Burn Care Group (NBCG) established to take forward • recommendations made by the National Burn Care Review • National Burn Care Standards published • London & South East of England Burn Network (LSEBN) • established • Interim configuration of services agreed • Peer review assessments conducted at 3 of the 4 specialised burn • services in London and the South East 2001 2003 Background 2004 2006 2009

15. Specialised burn services structure • Burn facilities (BF) caring for people with minor burns linked with local plastic surgery services. • Burn units (BU) providing regional level services caring for patients with a burn of moderate size and/or moderate complexity. • Burn centres (BC) supra-regional services caring for patients with the most complex injuries.

16. Current service provision

17. Accessibility for the population served. • Gaps in service provision. • Capacity – total capacity is adequate, but is not necessarily located in the right place. • Non compliance with national standards. • Lack of key onsite support services. • Lack of outreach services. • Lack of recognised services to manage less severe burn injury. • Risk of inability to cope with infection outbreak or major incident. Challenges in London and South East England

18. Demand and capacity • Evidence shows that the incidence and prevalence of burn injury increases in line with increasing levels of deprivation. • Current services are not positioned in areas of greatest need.

19. Gaps in service provision • Data shows a high number of hospital admissions to non specialised burn services. • This may be attributable to the current distances between specialised burn services and gaps in the north eastern part of the network. • It is likely that some patients may not be receiving optimal care as a result.

20. Patient flows • Evidence shows that prevalence of burn injury increases with increasing population density. • Currently, three out of four providers take a significant proportion of their patients from London.

21. A clinically agreed statement of the co-dependencies and co-location requirements for each tier of specialised burn services Clinical co-dependencies (1) • Purple (E1) – essential requirement (essential onsite co-location to deliver a minimum and safe service. • Lilac (E2) – essential requirement (desirable onsite co-location, otherwise must be provided through outreach). • White (O) – optimal (onsite co-location to deliver an optimal service).

22. Clinical co-dependencies (2) • A model of care for specialised burn services: Co-dependencies framework will be published alongside the case for change, and is available upon request.

23. Key components: • Workforce • Evidence suggests that consultant led services improve outcomes. • Current services do not meet national recommendations for consultant cover. • Lack of specialised burns nurses. • Lack of provision for surgical training in specialised burn care. • Network working • Lack of support for local hospitals and emergency departments. • Lack of outreach services to improve access to care. • Links with other agencies to need to be improved to ensure good follow up care and care of patients with long term health needs. • Major incident planning and infection outbreak • Capacity is potentially in the wrong place to cope with a major incident. • Limited capacity to cope with outbreaks of infection. Supporting the delivery of care

24. The NHS has a responsibility to ensure that services are financially • sustainable, deliver high quality care and provide value for money. • Challenges in ensuring the financial sustainability of specialised burn • services: • Disparity in cost of care at different services. • Variances in cost of care across PCTs. • Lack of quality measures to audit quality of care provided. • Lack of national tariff for specialised burn care. Financial sustainability

25. Issues and challenges facing current services need to be considered in line with the national and local strategic context • Current services do not comply with appropriate care standards and national recommendations • The network of care does not work as effectively as it could do • There are gaps in service provision in some areas of the network and a lack of provision for the treatment of minor burn injuries • Some patients are travelling too far to access the care they need • The way that specialised burn care in London and South East England is delivered must change in order to improve services for patients Summary

26. London and South East EnglandSpecialised Burns Project The case for change: Q&A session Robert Creighton Senior Responsible Officer, London and South East England Specialised Burns Project Former Chief Executive, Ealing, Hillingdon and Hounslow PCTs Transitional Director, London Public Health

27. London and South East EnglandSpecialised Burns Project Stakeholder engagement event 20th July 2011 The Hilton Hotel, Gatwick

28. London and South East EnglandSpecialised Burns Project The national perspective Nathan Hall National Burn Care Programme Lead NHS Specialised Services

29. The National Network for Burn Care (NNBC) aims to improve the quality of burn care services in England and Wales. • A key objective of the NNBC is to implement recommendations of the National Burn Care Review (2001). • The membership reflects the interests of several groups involved in burn care including: 4 regional burn care networks, NHS specialised commissioners, patient and carer representatives. • Several members of the NNBC are involved in the London and South East England specialised burn project: Ken Dunn, Teresa Warr, Becky Martin, Greg Williams, Pete Saggers, Sean Overett, Nathan Hall. • We aim for joined up working and co-production. Background

30. Specialised burn care – England and Wales

31. National Burn Care Standards • The national burn care standards have been updated and are currently available for comment. • The nationally agreed standards describe the clinical processes and structures that will deliver optimal outcomes. • Key deliverables: • Burn Care Standards and assessment process (October 2011) • Agreed outcome measures, used alongside the Burn Care Standards, to measure service quality. • National service specification (November 2011). NNBC work (1)

32. Information to Improve Quality • Key deliverables: • National clinical dataset for all patients receiving burn care (including in plastic surgery services). • Data analysed and reported to inform effective commissioning and quality improvement. • Develop nationally consistent contract currencies. • National Audit. NNBC work (2)

33. Major incident planning • NHS Emergency Planning Guidance: Planning for the Management of burn injured patients in the event of a major incident. • Burn Network & Burn Service Burn Major Incident Plans • 4. Other relevant projects • Burn Care Guidance for Major Trauma Networks (to be finalised late summer). • National Severity Thresholds. • National Patient Experience Survey. NNBC work (3)

34. For further information: • www.specialisedservices.nhs.uk/burncare nathanhall@nhs.net Contact details

35. London and South East EnglandSpecialised Burns Project Developing a model of care Ken Dunn Chair of the Clinical Expert Panel, London and South East England, Specialised Burns Project Consultant Plastic Surgeon, University Hospital South Manchester

36. Introduction The purpose of this session is to introduce the concept of a model of care and to invite discussion and feedback on the development of a model of care for specialised burn services in London and South East England. There will be three parts to this session: • Overview and background. • Discussion sessions. • Feedback from groups and further opportunity for questions.

37. Key themes from the case for change • Capacity – total capacity is adequate, but is not necessarily located in the right place. • Gaps in service provision in some areas. • Accessibility and travel times for patients. • Lack of recognised services for the treatment of minor burn injuries. • Current services do not comply with national standards and the requirements identified by the co-dependencies framework. • Lack of adequate provision of training in specialised burn care. • Lack of outreach services and links with other agencies.

38. Components of the Model of Care The model of care will be comprised of the following: • Review and evaluation of existing national and international service models to determine the most appropriate service model. • Recommendations for improvements to service delivery. • A range of potential configuration options (non site specific/ no geographical locations). • Care pathway aligned to the agreed service model.

39. Existing service models • Reviews of existing service models in other healthcare systems: • Europe • United States • Australasia • Other developing countries • Conclusions drawn from literature on existing service models: • need for a regional and integrated approach for patients with serious burn injury • centralisation of burn injury services to improve expertise and ensure good clinical outcomes • service delivery through formal clinical networks • integration with trauma systems/ networks • access should be optimised for populations where need is greatest

40. Proposed service model • Burn facilities (BF) caring for people with minor burns linked with local plastic surgery services. • Burn units (BU) providing regional level services caring for patients with a burn of moderate size and/or moderate complexity. • Burn centres (BC) supra-regional services caring for patients with the most complex injuries.

41. Model of care discussion session 1 In this session we would like you to consider answers to the following: • What are the key elements of an effective network of care for specialised burn services? • How could/ should an effective network of care for specialised burn services be supported? • What are the potential challenges to the development/ delivery of an effective network of care for specialised burn services? Specifically, tell us • How patients should move through the system. • Which teams should be involved in on going and follow up care. • The role of technology in supporting the care pathway. • How should communication with patients work? • At which points will the model differ for adults and children?

42. London and South East EnglandSpecialised Burns Project Group feedback: Model of care discussion session 1

43. Developing the configuration options A process will be designed to decide how many services will be needed at each level. Part of the model of care will outline the range of potential configuration options, based on the three tier model (non site specific and no geographical locations). Example A: 2 centres: 1 adult and paediatric centre (co-located) and 1 adult centre (no paediatrics) Example B: 3 centres: 2 adult only centres. 1 adult and paediatric centre (co-located) • The number of centres will dictate the number of units and facility level services required. • A number of options will assessed in order to identify an appropriate range.

44. Evaluating factors We have identified some factors which will influence the range and suitability of potential configuration options. Clinical factors: • Ideal patient throughput (minimum and maximum). • Size of population served. This will give us the optimum number of centres. Additional factors: • Provision of services for adults and children? • Resilience in the event of a major incident. • Value for money. • Access – to the specialised service at the time of injury. • Access – for follow up and ongoing care. • Workforce considerations The configuration of specialised burn services is one that should ensure it meets the health needs and requirements of the population.

45. Model of care discussion session 2 • Do you agree with these factors? • Are there are any additional factors that you think are important to consider? • Do any factors stand out as being particularly important.

46. London and South East EnglandSpecialised Burns Project Group feedback: Model of care discussion session 2

47. London and South East EnglandSpecialised Burns Project Next steps Robert Creighton Senior Responsible Officer, London and South East England, Specialised Burns Project Former Chief Executive, Ealing, Hillingdon and Hounslow PCTs Transitional Director, London Public Health

48. Case for Change • The case for change (full document & summary) will be presented for sign-off to Specialised Commissioning Board meetings in September 2011 (South Central, South East Coast, East of England & London). • Following their sign-off the documents will be published (Autumn 2011). • Co-dependencies Framework • The framework has been distributed today. • The full technical paper will be published alongside the case for change. • Patient & Public Engagement report • This will be presented to the project Steering Group for sign-off in July. • The report will be published alongside the case for change. Phase 1

49. Model of care This will be further developed with the Clinical Expert Panel following feedback from the stakeholder event today. This will be published late Autumn. Phase 1 (2) If you have any feedback or comments on the draft case for change or model of care development please e-mail the project team burns@londonhp.nhs.uk by 5thAugust. We will keep you updated about publications through our project update bulletin. Please let us know if you do not want to be on the distribution list.

50. Implementation of the model of care. This is likely to include: • A network approach to implementation. • Formal process to select providers based on their ability to deliver services in line with the model of care. • A proposal about Phase 2 of the project will be presented to Specialised Commissioning Group Board meetings in September 2011 (South Central, South East Coast, East of England & London). • We will continue to keep you updated about Phase 2 of the project through our project update bulletin. • Please let us know if you do not want to be on the distribution list. Next steps