Inefficiencies in provision of acute care with poor use of estate

1. Presentation given on 20 January 2012 Provision of Health Services in London • Inefficiencies in provision of acute care with poor use of estate • Dependence on hospital care with failure to transfer care to community • Need for more specialised care on fewer sites • Continuing health inequalities • Dissatisfaction with services

2. Healthcare for London Stroke Care Trauma Care Hospital ‘Reconfiguration’ Improving access to Primary Care ‘a comprehensive analysis of the need for change with principles to guide improvement in care’ Kings Fund Report 2011

3. Stroke reconfiguration • Evaluation Investigation of the incremental cost, effectiveness and cost-effectiveness of the new London Stroke Service in comparison with previous model. 6500 stroke episodes Short run: 3yrs after stroke Long run: 10 yrs after stroke Outcomes measured in deaths averted QALYs Analysis accounts for • Time from stroke onset to hospital admission • Time spent in hospital • Time after hospital discharge Analysis • At 30 days costs higher in new model by £3.3m. 214 fewer deaths. 51 additional QALYs • At three months costs lower by £5.4m. 238 fewer deaths. 112 more QALYs • At ten years for this cohort costs lower by £21m. 4492 QALYs gained • Cluster provide assurance to SHA on Implementation

4. HSMR by SHA NHS London shown in red The figure on the left compares the NHS London’s HSMR with other SHAs. The London figure is in red. NHS London’s HSMR has consistently been lower than all other SHAs. NHS London HSMR has reduced from 94.9 in 2005 to 84.9 in 2011. This is a decreases of 11%, the largest of any SHA. As the SHA is rebased every year, the English HSMR remains at 100 across all years. 4

5. Sustaining change • Concerns re financial and clinical sustainability • SAFE Project • Continuing concerns over quality and safety • Out of hours and weekend mortality • NCEPOD reports • Professional expressions of concern Formal Review of Adult Medical and Surgical Emergency Services

6. Variation in on-site availability On-call consultant surgeons • Weekdays range from 5 to 12 hours • Weekend ranges from 2 to 12 hours On-call consultant physicians • Weekdays range from 8 to 14 hours • Weekend ranges from 0 to 12 hours

7. Across London sites half of consultants are not always freed from other duties when on take Not freed Sometimes freedAlways freed • Over 50% of surgeons are not always freed from other duties whilst on-take • More than 50% of physicians are not always freed from other duties whilst on-take Source: London trust survey March 2011

8. Variation also exists in access to key diagnostics which are crucial to facilitate timely decision making and commencement of treatment Key diagnostics: X-ray, ultrasound, CT, MRI, interventional radiology and interventional endoscopy Source: Survey of London acute trusts (2011)

9. Key messages from the case for change • There are over half a million emergency admissions to London’s hospitals each year, amongst the sickest of our patients. • A patient admitted to hospital in an emergency has little choice in where or when they attend. The public trust and expect consistently safe and high quality services 24 hours a day, seven days a week; London is not meeting this expectation. • Workforce pressures such as EWTD, a future reduction in junior doctors and consultant sub-specialisation mean that the way services are currently delivered is not sustainable • The self-reported survey of London Trusts shows significant variation in service provision, especially out-of-hours. • Poor out-of-hours emergency service provision is associated with an increased variation in outcomes such as lengths of stay, re-admission rates and mortality rates

10. London needs to provide a seven day consultant delivered service to address the case for change Commissioning standards have been developed to address the issues raised in the case for change: to ensure that consultants have early and continued involvement in the care of all patients admitted as an emergency The development of the standards was clinically led and informed by the patient panel and wider stakeholder groups through continued engagement during the review Emerging standards were also shared with the Royal Colleges for feedback and comments throughout development The standards represent the minimum quality of care that patients admitted as an emergency should expect to receive in every hospital in London that accepts patients on an emergency basis All standards cover the seven days of the week – there should be no difference in the provision of emergency services during the week compared to those at the weekend

11. Commissioning: Core standards All emergency admissions to be seen and reviewed within 12 hours A clear multi-disciplinary assessment to be undertaken within 12 hours and a treatment plan to be in place within 24 hours All patients admitted acutely to be continually assessed using a standardised early warning system When on-take, a consultant and their team are to be completely freed from any other clinical duties/ elective commitments Consultant work patterns are to meet the demands for consultant delivered care with extended day working across the AMU/ ASU, seven days a week All patients on the AMU/ ASU to been seen and reviewed by a consultant during twice daily ward rounds All hospitals admitting emergency patients to have 24/7 access to key diagnostic services All hospitals admitting emergency patients to have 24/7 access to interventional radiology

12. Commissioning processes • Commissioning intentions 2012/13 • Standards will be included in pan-London commissioning intentions • Evidence to be sought from providers that standards are in place and for ongoing monitoring • Commissioning strategy planning 2012/13 – 2014/15 • The commissioning standards should be integral to commissioner’s plans • Plans are expected to outline the likely service impact for providers following discussion • System wide approach • In the event some providers are not able to meet the standards a process to evaluate the range of options available to commissioners to deliver the standards is proposed

13. Additional Critical Services • Paediatric Medicaland Surgical Services • Critical Care and Anaesthesia • Emergency Medicine • Maternity Services • Interventional Radiology • Emergency Orthopaedics (Fractured NoF)

14. The Future • London Clinical Commissioning Council • London Clinical Senate • Senate Council • Professional Advisory Groups