Sussex Health Overview and Scrutiny Committee
Thursday 2 December 2022
Reconfiguration of Cardiology Inpatient and Cardiac Catheter Lab Services at Maidstone and Tunbridge Wells NHS Trust
Report from: Amanjit Jhund, Director of Strategy, Planning and Partnerships
Maidstone and Tunbridge Wells NHS Trust
Peter Maskell, Medical Director, Maidstone and Tunbridge Wells NHS Trust
Author: JoAnne Cutting, Programme Director
Maidstone and Tunbridge Wells NHS Trust
1. Introduction:
This paper outlines the current cardiology service provided by Maidstone and Tunbridge Wells NHS Trust (MTW), our case for change, and our plans for reconfiguration of our cardiology inpatient and cardiac catheter laboratories. We believe we have a strong case for change to improve the quality of the service and care for our patients, meet national clinical quality standards and develop a specialist cardiology service which supports the Trust’s future clinical strategy. We need to find a sustainable way to provide specialist inpatient cardiology services for the population of west Kent and beyond, including patients in our catchment population on the Kent/Sussex border and in the north of East Sussex.
2. Current service and scope
The current cardiology inpatient service at Maidstone and Tunbridge Wells NHS Trust (MTW) is provided at both Maidstone and Tunbridge Wells Hospitals. There is a cardiac catheter laboratory on each hospital site with the Tunbridge Wells site providing angioplasty intervention and simple pacing procedures and the Maidstone site providing simple and complex cardiac pacing and electrophysiological intervention. As a result of this, patients admitted to Maidstone Hospital requiring angioplasty will require transfer as an inpatient for the procedure to Tunbridge Wells Hospital, and patients admitted to Tunbridge Wells Hospital requiring complex pacing will require transfer as an inpatient to the Maidstone site. Both sites have a 6-bedded coronary care unit. Cardiology inpatients outside of the coronary care unit are managed on general medical wards on each site, with a nominal allocation of beds on specific wards. Both hospital sites provide outpatient services and outpatient diagnostics, and outpatient clinics are also provided at Sevenoaks and Crowborough hospitals.
We are clear that our focus for any proposed change is on our specialist inpatient cardiology services. We do not plan to change outpatient clinics or outpatient diagnostics, which would still be delivered from Maidstone Hospital, Tunbridge Wells Hospital, Crowborough Hospital and Sevenoaks Hospital. Patients attending A&E with cardiology symptoms would continue to be seen and treated in A&E at both Maidstone and Tunbridge Wells Hospitals, transferring if necessary (transported by ambulance or patient transport services) should they need to be admitted as an inpatient.
3. The case for change
The case for change is driven by a number of factors: -
· Patients having their treatment delayed due to inter-site transfers during an inpatient stay
· Poor patient experience and disruption for inpatients if they have to be transferred between sites
· The Trust inability to provide a specialist cardiology service in a dedicated cardiology ward outside of the coronary care unit on either hospital site
· Diluted services due to the necessary duplication across two sites requiring onerous and unacceptable on-call arrangements for our cardiologists and other specialist staff
· Difficulty in recruiting and retaining specialist staff because the way services are currently organised doesn’t meet with best practice and has onerous on-call rotas
· Non-compliance with 9 of the 25 ‘Get It Right First Time’ (GIRFT) national programme clinical standards as detailed below.
Non-compliant MTW GIRFT requirements
|
GIRFT Recommendation |
|
|
1 |
All hospitals must deliver cardiology services as part of a defined and agreed network model. |
|
2 |
All hospitals receiving acute medical admissions must have a consultant cardiologist on-call 24/7 who is able to return to the hospital as required. There should be a consultant job planned specifically to review newly admitted and acutely unwell inpatients 7/7 and a consultant job planned (note this may be the same consultant) to deliver 7/7 review of other inpatients, ensuring continuity of care. This requires a minimum 1 in 6 consultant rota |
|
4 |
All members of the wider heart team should be supported to work in extended roles and trusts should ensure that appropriate staff (including ACPs, specialist nurses and cardiac physiologists) are trained, accredited and authorised to prescribe medications relevant to their role. |
|
5 |
Each network must ensure that there are clearly defined patient pathways covering all acute hospitals for the provision of 24/7 emergency temporary pacing and 7/7 permanent pacing. |
|
7 |
Networks should ensure that stable chest pain pathways are consistent with the recommendations of NICE CG95. Invasive angiography should, as a default, be performed as ‘? proceed’ and must be performed in PCI-enabled Cath lab by a PCI-trained operator. |
|
8 |
Networks must ensure that all hospitals performing PCI have a 24/7 on-site rota for urgent return to the Cath lab. |
|
10 |
For the acute chest pain pathway, all networks should provide 7/7 ACS lists, accessible to all hospitals in the network. Coronary angiography ‘?proceed’ should be performed within 72 hours for patients without high risk features, within 24 hours for high risk patients and within 2 hours for the highest risk patients. Where cardiac surgery is required, this should by default be undertaken within seven days of coronary angiography. |
|
11 |
In each hospital there should be a specialist consultant lead for HF, supported by a multidisciplinary HF team. Secondary care services should be integrated with community teams, with regular joint multidisciplinary meetings (MDMs). (this will be resolved when a new consultant joins the team in December 2021) |
|
15 |
Networks should ensure that all hospitals admitting acute cardiology patients have 24/7 access to emergency echo including the facility for immediate remote expert review as required. Elective/urgent echo should be routinely undertaken 7/7. Urgent TOE should be available 7/7 and delivered on a network basis). |
Our proposal to address the case for change
In order to meet the GIRFT clinical quality standards, and to address the other factors set out above in our case for change, doctors and other specialists in the MTW cardiology team believe there should be a consolidation of the most specialist and inpatient cardiology services on one of either the Maidstone or the Tunbridge Wells hospital sites. Whilst centralising the inpatient and cardiac catheter laboratory services on one hospital site will result in an increase in travel time for some patients, the aim is to improve the patient pathway, improve access to intervention and ultimately reduce the time patients are required to stay in hospital. As well as enabling the delivery of the GIRFT recommended clinical quality standards, centralisation of this element of the service is in line with the Kent and Medway Joint Strategic Needs Assessment, and the Health and Wellbeing Strategy. These both recognise the benefits of providing single site specialist services.
Kent JSNA – the Joint Strategic Needs Assessment
“For those people with more serious of life-threatening emergency care needs, we should ensure they are treated in centres with the very best expertise and facilities in order to maximise the chance of survival and a good recovery”
Kent HWBS – the Health and Wellbeing Strategy
“One of the key issues that we need to tackle is that of public awareness of the changes that will be taking place over the coming years, namely the move to more care being delivered in local communities away from acute hospitals. This will inevitably mean major changes to our big hospitals, with the creation of specialist hospitals where good quality care can be provided with specialist trained staff, with general services provided in the community at a local hospital as clinically appropriate. This may mean an increase in journey times to access specialist provision for some people but conversely will allow people to access much more of the care they need in community settings.”
In addition, the East Sussex Joint Strategic Needs Assessment on cardiovascular disease (May 2019) emphasises that achieving the national ambitions to reduce cardiovascular disease (CVD) in the population requires a whole system effort. The pathway starts with prevention, through primary care and community support, through to the most specialist treatment provided in an acute hospital for a small percentage of people. MTW wants to provide the best service it can for all cardiology patients in its care, but other elements of the pathway are as important. The JSNA reports the uptake of the NHS Health Check screening in East Sussex is very good compared to the rest of England. It states that improving the uptake of CVD screening in hard to reach populations and implementing interventions to reduce CVD risk will continue to reduce inequalities in the East Sussex population. We will continue to work in partnership with health and care colleagues in the Kent and the Sussex systems on all aspects of the patient pathway.
4. Proposed centralisation of MTW’s cardiology inpatient and cardiac catheter laboratory services
The proposed changes would mean the development of a ‘hot’ site for cardiology – i.e., a site that focuses on delivering more complex care, providing: -
· 12 Coronary Care Unit beds
· 2 co-located cardiac catheter laboratories for both elective (planned) and emergency procedures
· Up to 24 dedicated cardiology beds
· Consolidated skills and facilities on one site for the provision of care to patients with the most complex cardiology conditions
· Consolidation of lab staff onto one site to provide 24/7 on call and weekend lab activity.
The other site would be a ‘cold’ site for cardiology – i.e., a site that focuses on delivering more routine and less complex cardiology care - providing: -
· On site cardiologists 5 days a week with weekend advice from the ‘hot site’ for the management of less serious cardiology conditions or where the cardiology condition is secondary to another illness.
Both sites would still provide emergency department access for all patients, outpatient clinics and non-invasive diagnostic investigations and specialist outpatients, for example heart failure and arrythmia clinics. Added to this outpatient clinics will continue at both Crowborough and Sevenoaks Hospitals.
The benefits of the proposed new configuration would be: -
· Delivery of a 7-day service with consolidated workforce (working to a more reasonable on-call rota) and specialist facilities that can be maximised
· Improved availability of nursing and technical teams skilled in complex care that will improve the quality of care we can give to patients
· More streamlined and efficient care resulting in shorter stays and a better experience for patients
· Improved continuity of clinical personnel
· The ability to develop the service and provide even more specialist cardiology services for our catchment population in the future, in line with the Trust’s clinical strategy
5. Options
There are currently 4 options being considered by the Trust:
1. No change – with just incremental improvement attempts as part of our ‘business as usual’ but without the opportunity to make transformational changes
2. Consolidation of specialist inpatient cardiology services on the Maidstone site through reconfiguring existing space
3. Consolidation of specialist inpatient cardiology services on the Maidstone site through some new building and some reconfiguration of existing space
4. Consolidation of specialist inpatient cardiology services on the Tunbridge Wells site by reconfiguring existing space.
In July 2021 Kent HOSC members discussed and reviewed our case for change and our emerging proposals with the four potential options. Kent HOSC determined that these proposals represented a significant change but did not amount to a ‘substantial variation’. HOSC members confirmed therefore that formal consultation with the local authority was not required. However, in recognition of the potential significant change outlined the members supported a 12-week engagement period with the public to discuss the proposals, and gather insights, views and feedback before the Maidstone and Tunbridge Wells NHS Trust Board decides on the final configuration of these services. We launched a 12-week public engagement period on 22nd October 2022 which will run until 14 January 2022. It builds on some early patient, staff, stakeholder, and public engagement the trust has already undertaken on this issue.
At this point, no decision has been made and there are a number of factors to consider in weighing up the options. The ‘no change’ option won’t address and deliver on our case for change, so is our least preferred option at this stage. Consolidation options at Maidstone would have the added benefit of co-locating inpatient cardiology with the new Hyper Acute Stroke/Acute Stroke Unit service, with some shared co-located expertise and support services and is therefore the Trust’s preferred option. Reconfiguring existing space would be quicker and cheaper than building new space. The option to consolidate within existing space at Maidstone hospital would be the most cost-effective and quickest to implement option while consolidating inpatient cardiology on the Tunbridge Wells site would be more expensive and take longer due to the nature of the PFI contract on the building.
Despite having a preferred option, the trust has not yet decided how cardiology services will be organised in the future, and won’t until views and feedback from the engagement period have been carefully considered. This will be alongside all the other evidence – clinical, quality, workforce, financial, estates - gathered as part of the trust’s review of cardiology services.
6. Impact on Sussex patients
The map and distribution charts below show the patient population both Maidstone and Tunbridge Wells Hospitals serve. They also highlight the current patient flows from the Kent/Sussex borders. The impact of our proposals on this cohort of patients would be determined by and depend on which of the Maidstone or Tunbridge Wells sites was chosen for the proposed centralisation of inpatient cardiology services. Clearly centralisation on the Maidstone site would have more impact in terms of travel times for Sussex-based patients, particularly by public transport. However, we would hope to mitigate the impact of this by improved care and shorter length of stay. We would also want to consider measures that could be put in place or expanded to support patients or loved ones that don’t have access to a private car and may struggle with travelling to or visiting someone in hospital.
In terms of the extent of the impact these proposals would have on Sussex-based patients it is important to consider too the volumes of patient activity currently using MTW’s specialist inpatient cardiology services.
Outpatient services will continue to be provided on the current 4 sites including Crowborough Hospital. Sussex-based patients attending MTW cardiology outpatient clinics, outpatient diagnostic services, or presenting at A&E with cardiology symptoms would continue to use the services they use now, at the locations they go to now.
The three tables below outline the MTW activity volumes for Sussex-based cardiology patients.
· Table 1 shows the overall trust activity 3-year average (2017-2019). Sussex based patients make up 10.4% of the overall total of 23592. The bulk of this is outpatient activity. The elective day cases, elective inpatients, and non-elective inpatients for Sussex totals 249 patients. This is 6.7% of total trust activity for these three categories
· Table 2 shows the last two years’ Sussex CCG activity for cardiology split by hospital site highlighting the majority of the Sussex-based patient activity is at Tunbridge Wells Hospital as anticipated. However, the bulk of the activity is outpatient appointments which will not change, and a portion of elective procedures already come to the Maidstone site
· This is further reinforced in Table 3 which shows circa 90% of the total Sussex based cardiology activity is outpatients activity.
Table 1
|
Cardiology Activity |
Trust total (all CCG's) |
Sussex CCG's 2019-2020 |
% of Total |
|
2017-2019 (3-year average) |
|
|
|
|
Elective Day Case |
1174 |
141 |
12.0 |
|
Elective Inpatients |
224 |
24 |
10.7 |
|
Non-Elective Inpatients |
2311 |
86 |
3.7 |
|
Outpatients |
19883 |
2204 |
11.1 |
|
TOTAL |
23592 |
2455 |
10.4 |
Table 2
|
Sussex CCGs |
TOTAL |
Crowborough |
% |
Sevenoaks |
% |
Maidstone |
% |
Tunbridge Wells |
% |
|
2019/2020 |
|
|
|
|
|
|
|
|
|
|
Elective Day Case |
141 |
|
|
|
22 |
|
119 |
|
|
|
Elective Inpatients |
24 |
|
|
|
4 |
|
20 |
|
|
|
Non-Elective Inpatients |
86 |
|
|
|
5 |
|
81 |
|
|
|
Outpatients |
2204 |
135 |
|
11 |
|
119 |
|
1939 |
|
|
TOTAL |
2455 |
135 |
5.5 |
11 |
0.4 |
150 |
6.1 |
2159 |
87.9 |
|
2020/2021 |
|
|
|
|
|
|
|
|
|
|
Elective Day Case |
91 |
|
|
|
11 |
|
80 |
|
|
|
Elective Inpatients |
22 |
|
|
|
1 |
|
21 |
|
|
|
Non-Elective Inpatients |
61 |
|
|
|
|
|
61 |
|
|
|
Outpatients |
1984 |
134 |
|
10 |
|
109 |
|
1731 |
|
|
TOTAL |
2158 |
134 |
6.2 |
10 |
0.5 |
121 |
6.1 |
1893 |
87.7 |
Table 3
|
Sussex CCGs |
TOTAL |
% of Total |
|
2019/2020 |
|
|
|
Elective Day Case |
141 |
5.74 |
|
Elective Inpatients |
24 |
0.98 |
|
Non-Elective Inpatients |
86 |
0.86 |
|
Outpatients |
2204 |
89.78 |
|
TOTAL |
2455 |
|
|
2020/2021 |
|
|
|
Elective Day Case |
91 |
4.2 |
|
Elective Inpatients |
22 |
1.0 |
|
Non-Elective Inpatients |
61 |
2.8 |
|
Outpatients |
1984 |
91.9 |
|
TOTAL |
2158 |
|
Fig 1: Map of current patient population using cardiology services
Fig 2: Distribution of patient activity
We are working closely with colleagues in Sussex CCG and ESHT, who, as you are aware, are also developing proposals to improve cardiology services. We will continue to work together, and with SECAmb, and keep each other informed of the detail of our respective reviews. We will work to ensure alignment across the wider geography and to deliver the maximum benefit and quality outcomes in cardiology services for the people of Kent and East Sussex.
7. Engagement activities, including for the Sussex population
MTW has developed a substantial engagement plan. The trust launched a 12-week period of engagement activity to discuss the cardiology improvement plans, as agreed with Kent HOSC, on 22 October 2021. The public engagement will run until 14 January 2022.
The engagement plan includes using a range of different methodologies to reach and hear from audiences across west Kent and the border communities of East Sussex. In our planning we recognise that whilst, particularly during the pandemic, more people are engaging digitally than ever before, there are still people who can’t or don’t want to engage digitally. We plan to exploit digital engagement and awareness-raising opportunities but have also used traditional methods, contact points, and printed materials for those who are not online. Core information, including our engagement document, is hosted on our website at www.mtw.nhs.uk/cardiology-engagement, but people can also phone or write to us to request printed information.
Our planned activity includes:
Publicity and awareness raising – through media releases and print adverts in local papers; posters displayed across the MTW sites and in local libraries; paid-for social media advertising – targeted by postcode (TN19, TN6 and TN2 with the largest volume of Sussex-residents’ MTW activity – see Fig 1 above) and including TN19 (Etchingham), TN6 (Crowborough), TN2 and TN5 (Wadhurst), TN7 (Hartfield), TN32 (Robertsbridge), TN20 (Mayfield), TN22 (Uckfield) postcodes from East Sussex; information cascade to stakeholders and to community and patient groups, including through Sussex CCG and Sussex Healthwatch and their patient and public engagement channels; information cascade to cardiology and other staff at Maidstone and Tunbridge Wells hospitals and others in the health and care system in Kent, Medway and East Sussex
Public and staff online listening events – open to anyone interested in learning more about and discussing the proposals. The dates for the public listening events are:
· Thursday 9 December 2021,19.00 – 20.30
· Wednesday 15 December 2021, 19.00 – 20.30
Details of how to register and join are available on the MTW website. These meetings are being advertised on our website and through local newspaper and social media adverts as well as through our information cascade to stakeholders, community, and patient groups
An online and printed questionnaire – on our website and available hard copy for those not online
Focus groups with those with protected characteristics under the equalities’ legislation, with seldom heard and marginalised groups, with those across the catchment geography (including East Sussex), and with those most impacted by our proposals. These are being held throughout the 12-week period and will be proactively recruited to and run via an engagement agency to ensure a representative sample of people from our targeted audience groups
‘Pop-up’ information stalls in shopping centres in Tunbridge Wells, Maidstone and other areas including in Crowborough in East Sussex (dates are still being confirmed for some of these and further information can be found on our website, which will be kept updated throughout the engagement period)
Telephone polling – research with a representative sample of the population drawn from the post-code areas shown above in Fig 1 in the MTW catchment area, including the postcodes from East Sussex
Attendance at existing meetings and forums to present and discuss the case for change and proposals, and to hear views – for example, the Tunbridge Wells Older People’s Forum. We are open to invitations to come and speak at community or patient group meetings – the team can be contacted via our website
Engaging with and briefing key stakeholders – such as Kent HOSC, Sussex HOSC, MPs across west Kent and the border communities of East Sussex.
At the end of our 12-week engagement period the results and feedback will be collated and independently analysed by an agency, with a thematic report delivered to the Maidstone and Tunbridge Wells NHS Trust board to help inform and support their decision-making. We would be happy to share this report with Sussex HOSC too.
We expect the MTW board to consider all the evidence collected throughout our review and to decide on the future shape of specialist inpatient cardiology services across the trust in February 2022.
Any agreed changes to the way cardiology services are organised with then be subject to detailed implementation planning. There won’t be any sudden overnight changes but rather a planned transition. We commit to keeping staff, patients, stakeholders – including Sussex HOSC, and the public updated as our plans progress.
Recommendations
Members are asked to:
· Consider and note the case for change, and the proposals and options to help address it to improve the quality of specialist inpatient cardiology care for patients at Maidstone and Tunbridge Wells NHS Trust
· Consider the impact of the proposals and whether they are substantial variation of service for Sussex residents
· Agree with colleagues from MTW how they would like to be kept updated about this work as it progresses.
Appendix A – Improving cardiology services, our engagement document