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Date: |
November |
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Version: |
1 |
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Name of originator/ author: |
CCG Programme Team |
Contents
5.0 How we developed our proposal
Executive Summary
1.0 Purpose
The purpose of this Pre-Consultation Business Case is to describe the wide engagement to date in communicating the drivers for change, reviewing all possible options to transform ophthalmology services provided by East Sussex Healthcare NHS Trust to deliver the best possible care for local people. The Pre-Consultation Business Case includes the available information and evidence that has supported the development of a model of care, an analysis of possible options to deliver this model of care, and it proposes preferred viable options to transform ophthalmology services.
This Pre-Consultation Business Case recommends to the East Sussex CCG (via Joint Sussex Committee delegated authority) one option to take forward to public consultation and, if approved by the CCG, to submit to the East Sussex Health Overview Scrutiny Committee who will decide if they consider this constitutes substantial variation to services and that they would like the CCG to consult with them on this.
The full pre-consultation business case and associated document including the Equality and Health Inequality Impact Assessment, Quality Impact Assessment, the pre-consultation engagement report and options development and appraisal reports will all be available and published on the CCG websites.
2.0 Context
In 2019, the NHS Long Term Plan was published outlining the ambition that the NHS will increasingly be: more joined-up and coordinated in its care; more proactive in the services it provides; and more differentiated in its support offer to individuals, with the aim being that population health would be improved through coordinated service planning and delivery[1].
In alignment with the Sussex Health and Care Partnership, in 2019 the East Sussex system - East Sussex Clinical Commissioning Group (CCG), East Sussex County Council (ESCC), East Sussex Healthcare NHS Trust (ESHT), Sussex Community NHS Foundation Trust (SCFT) and Sussex Partnership Foundation NHS Trust (SPFT), developed its’ East Sussex Health and Care Plan. This built on improvements over recent years including:
· A comprehensive and co-ordinated range of preventative services
· Ongoing development of community health and social care services
· Strong whole system performance
· An Integrated Outcomes Framework to better enable us to measure whether our work as a system (activity) was having the desired results (outcomes)
· Developing our approach to understanding and using our collective resources on a system wide basis for the benefit of our population.
3.0 Our population
East Sussex has amongst the highest numbers of over 65-year olds and over 85-year olds in the country, and this is expected to grow further. Within this, many people live their later years in ill-health, often with more than one long term condition. This means that increasing numbers of people are needing to use local health and care services that are not always designed to support the growing numbers of local people needing their support. This increase in need is being felt within the system across Sussex and locally, with significant increases in people needing ophthalmology services in recent years. The system needs to reflect on how best to meet these changing population needs, recognising the needs of people living in areas of deprivation, and to rethink how we deliver an equitable service that can ensure the best health outcomes for our population, and can adapt to the challenges of the future, and represents good value.
The recognition of the changing needs of the population, the changing nature of ophthalmology care and the associated challenges in providing ophthalmology services has made the redesign of ophthalmology a key priority for East Sussex system. Our overall objectives are to:
· improve health, experience and quality of care
· improve the overall sustainability of health and social care services.
Delivering financial sustainability will also contribute to delivering these broader objectives.
4.0 Case for Change
We have reviewed the strategic drivers for change, the existing ophthalmology services for children and adults and the availability of other relevant existing and new services. This led us to the following conclusions:
· Quality: Healthcare systems are required to minimise the risk of significant harm, through delivering timely follow-up for patients with chronic conditions. The high and growing number of these cases within ophthalmology makes this a challenge.
· Service performance: nationally, ophthalmology outpatient services are the largest of all outpatient services that people use, with East Sussex Healthcare Trust seeing 18,075 new outpatients and 65,511 follow-up appointments in 2019-20. The Covid-19 pandemic has impacted heavily on ophthalmology provision and this, coupled with the very high levels of need for care, has led to East Sussex Healthcare Trust no longer meeting national waiting time standards.
· Growing need: It is estimated that, over the next 20 years, the need for cataract services will rise by 50%, glaucoma cases by 44% and medical retina by 20%.
· IT / Digital: there would be a significant benefit to patients through ophthalmology services making the best possible use of modern digital technology, such as an Electronic Eyecare Referral System (EERS). Modern technology presents opportunities to improve patient pathways and better manage the growing need for ophthalmology services.
·
Workforce: a census carried out by the Royal College of
Ophthalmologists (RCOphth) in 2019 identifies gaps in recruitment
for ophthalmologists and workforce planning, amid a predicted 40%
increase in need over the next 20 years.
· The national Getting it Right First Time (GIRFT)[2] programme reviewed the ophthalmology service in March 2018. It was recommended that:
o Review pre-assessment clinics and review/audit coding for complex cataracts to ensure the patient pathway for cataract surgery is optimised.
o Continue to develop health care professional (HCP) staff by training and developing all members of the multi-disciplinary team, whilst utilising competency frameworks to increase the number of non-consultant clinical staff.
o Look into using consultant-led and technician-provided virtual clinics for age-related macular degeneration (AMD) and glaucoma to improve refinement of treatment plans.
o Review of coding practices to ensure accuracy, particularly around complex cataracts, corneal grafts, strabismus follow-ups and vitreo-retinal conditions.
o Continue to refer to the Royal College of Ophthalmologist’s “The Way Forward”[3]document to identify options to help meet demand and the Common Competency Framework to support health care professional staff development.
· Net Zero NHS: the NHS is committed to reach net zero carbon by 2050 which means we need to significantly reduce carbon emissions caused by procedures, travel, estates, etc. The NHS Long Term Plan encourages service delivery to happen virtually, where appropriate.
· Estates and equipment: diagnosis and monitoring of ophthalmic patients is highly dependent on equipment. Much of the equipment currently used by the department across its three sites is old, which impedes the service’s ability to work efficiently and effectively. There are limitations of physical space in the current service configuration limiting the capacity of the service to meet the current and growing need of the local population which contributes to challenges in meeting service standards.
· Making best use of our resources: we want to ensure that our services are delivered in a way that gives the greatest benefit for local people.
As a result this Pre-Consultation Business Case proposes changes to a range of ophthalmology services provided by East Sussex Healthcare NHS Trust.
5.0 How we developed our proposal
Following analysis of the current service provision and the emerging future needs of local people, we developed a ‘Case for Change’ that outlined the key drivers for service transformation. This provided the basis for our engagement with local people, clinicians and other professionals to further understand what is important to them about ophthalmology services. This engagement has indicated several key themes:
· Care provided
· Equality and Diversity
· Access and transport
· Clinical services
· Community optometry.
Alongside finding out what is important to local people and clinicians, we have reviewed local health needs in East Sussex. This tells us that there are some groups of local people who have particular needs and may be disadvantaged in accessing current services. We have taken account of these needs in our proposals and sought to mitigate those disadvantages through the proposals outlined in this Pre-Consultation Business Case (more detail on this can be found in Appendix 1 - Equality and Health Inequality Assessment of the full PCBC).
Following pre-consultation engagement, three options development and appraisal workshops (independently chaired and facilitated by Opinion Research Services - ORS[4]) took place, during March 2021, to identify and consider and refine possible options for the future provision of acute ophthalmology services, to appraise these options and make recommendations for preferred viable options.
Following this, and as part of our in-depth comparative analyses for this pre-consultation business case, we have also reviewed quality indicators, travel analysis, the impact this transformation could have on other services (within Sussex and outside of Sussex), the impact this transformation could have on the equality and health inequalities of our population, and the financial feasibility of each option.
6.0 The process of assurance
When developing our options, our final draft proposals, and this Pre-consultation Business Case:
· We have considered the outputs from engagement with local people and clinicians and used these to inform the Pre-Consultation Business Case.
· We have developed the Pre-Consultation Business Case with due regard to our duties to reduce inequalities and promote integration of health services where this will improve the quality of those services, in addition to ensuring compliance with all relevant equality duties.
· We have assessed the impacts of our proposal by undertaking a Quality Impact Assessment and an Equality and Health Inequalities Impact Assessment to identify any potential negative impacts and identified appropriate mitigating actions.
· We have taken into account the recommendations of the South East Clinical Senate.
· We have been informed by feedback from the East Sussex Health Overview and Scrutiny Committee.
· We have assessed our proposal against the NHS Four Tests for service reconfigurations.[5]
· We have developed our proposal and associated consultation plans in line with the Gunning Principles[6] to ensure that:
o a decision will not be taken until after public consultation
o local people and stakeholders have information that enables them to engage in the consultation and inform our decision;
o there is adequate time for people to participate in the consultation
o we will demonstrate how we have taken account of engagement and formal consultation by publication of a consultation feedback report describing this.
· We have considered opinions and insight from a number service leads and managers within our acute hospitals in East Sussex that represent a broad range of clinical specialties.
7.0 Our proposal
We are proposing to locate ophthalmology services at two hospital sites, Eastbourne District General Hospital and Bexhill Hospital, supported by one stop clinics at both hospitals and a diagnostic eye hub at Bexhill Hospital.
The introduction of one stop clinics and a diagnostic eye hub will ensure faster diagnosis, reduce waiting times, reduce number of appointments required for patients to attend and repeated tests. These are key quality improvements to the ophthalmology service.
To deliver this model of care we need to bring staff together across a range of disciplines into multidisciplinary teams and the proposal enables the physical space for these staff to work together in this way. This also improves access to senior decision making and input when it is required in relation to patient care so that patients will see the right people at the right time and reducing repeat attendances.
To help develop this Pre-Consultation Business Case we have engaged with local people and stakeholders. Our next step is to seek further feedback through a formal and public consultation process with local people and with the East Sussex Health Overview Scrutiny Committee. We will gather this feedback and comments and consider and respond to these before we make the final decision on the future of East Sussex Healthcare NHS Trust’s ophthalmology services.
If this Pre-Consultation Business Case proposal is approved by the CCG, and East Sussex Health Overview Scrutiny Committee consider that the proposal constitutes a substantial variation to services and should therefore be subject to consultation, then this process will begin in December 2021.
Through our engagement and options process we developed 5 options. The conclusion from our options appraisal is a proposal to take forward one option for formal consultation with patients, the public and local stakeholders. This is the option that has been appraised as the one that will best provide good patient experience, support improved outcomes for local people and a high-quality sustainable service that enables the model of care to be implemented that will realise these benefits and is deliverable.
We currently provide services from three sites: Eastbourne District General Hospital, Conquest Hospital, Hastings, and Bexhill Hospital. This proposal seeks to consolidate activity from Conquest Hospital to Bexhill (from three sites to two) and to continue the provision at Eastbourne to deliver the model of care. Bexhill Hospital is 6.6 miles from the Conquest Hospital, and both are outside of the Hastings town centre. The activity in the scope of this proposal relates only to outpatients and Day Cases at the Conquest Hospital.
The proposed transformation, with the one stop clinics and diagnostic eye hub, will make key quality improvements to the service, such as:
· enable a redesigned ophthalmology pathway that will increase quality of care ensuring patients are seen by the right person, in the right place, and at the right time.
· ensure that we can better meet service standards so that patients receive care in a timely manner, meaning faster diagnosis, shorter waiting times, fewer repeat appointments for tests and therefore less travelling for patients.
· provide a consultant-led model of working that efficiently utilises skill mix across the workforce and provides training opportunities
· ensure staff and expert knowledge are consolidated, allowing for improved supervision and opportunities for training and educational needs for staff who wish to upskill. Thereby, gradually improving the skills in the workforce to improve the service quality and care provided to our population.
This option will have positive impacts for our patients, as well as workforce, and will improve patient experience, patient outcomes and our performance against national standards in the long term (by reducing waiting times alongside travel for patients), whilst making the service more efficient and sustainable for the future. It also supports the wider Sussex Ophthalmology plan enabling future training and supervision from ophthalmology consultants to upskill the community Optometry workforce.
The national and regional/local transformation of ophthalmic services, together with the demands inherent in meeting future standards and the challenging aspects of a fragmented service and workforce, mean that doing nothing means that there will be increasingly poor and fragmented access to ophthalmology services for local people. The other options were not taken forward as they either scored poorly as part of the options appraisal process, involve aspects of ophthalmology services that are out of scope for this programme of work, or are not viable following thorough financial and activity-based analyses, as part of this Pre-Consultation Business Case.
In addition, the options appraisal process showed there was a clear preference across all stakeholder groups for a combination of Eastbourne District General Hospital and Bexhill Hospital sites provision under Option 2. Combinations of site provision that included Conquest Hospital were least favoured.
Over time, as part of the longer-term vision to continue to improve ophthalmology services, we will consider the needs of the following ophthalmology service provision at East Sussex Healthcare NHS Trust (e.g. pre/post op cataract pathway, glaucoma referral refinement) alongside enhanced service provision in the community, provided by local optician practices, across East Sussex
However, at this current point the significant opportunity available to the system to transform ophthalmology services, providing one stop clinics and a diagnostic eye hub is key. Longer term service consolidation, delivered in alignment with the Sussex-wide Ophthalmology Transformation programme would also enable improved joined up service provision across community and hospital settings, consolidating staff and resources to best serve the local population. This is not the subject of these proposals and if plans are developed into the future, these would be subject to further engagement.
These options (described in more detail in Section 8) will have positive impacts for our patients, as well as workforce, and will improve our ability to meet service standards and patient outcomes in the long term, through a more efficient service and one that is more sustainable for the future.
We will continue to work with local people and stakeholders to understand the implications of our proposal through the consultation process. This will include working with local people and stakeholders to understand how best to provide easily accessible information to support local people and professionals about the proposed change.
We recognise that this will represent a change for some people who currently use these services and we will continuously engage with local people and stakeholders throughout the consultation process to understand the implications of our proposal. All new information and evidence gathered as part of a consultation will inform a final proposal.
Once a decision is reached, during any implementation and transition stages we will ensure that changes are communicated in a clear and timely manner. This would include working with local people and stakeholders to communicate any changes to existing services, the nature of new services and how to access them and to ensure people who use these services at East Sussex Healthcare NHS Trust continue to access the care and support they need.