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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 (PCBC) is to describe the wide engagement to date in communicating the drivers for change, reviewing all possible options to transform cardiology 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 acute cardiology services, including inpatients and interventional services.
This Pre-Consultation Business Case recommends to the East Sussex CCG (via Joint Sussex Committee delegated authority) two options 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 (SHCP), 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 in 2019. 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
- 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. The NHS Long Term Plan outlines that heart and circulatory disease, also known as cardiovascular disease, causes a quarter of all deaths in the UK and is the largest cause of premature mortality in deprived areas. With elderly patients and those who live in areas of deprivation tending to have higher prevalence of cardiovascular disease, the system needs to reflect on how best to meet the changing needs of the local population, 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 cardiology care and the associated challenges in providing cardiology services has made the redesign of cardiology 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 cardiology services and the availability of other relevant existing and new services. This led us to the following conclusions:
· Subspecialisation – cardiology has become increasingly complex and specialised and the current configuration of services limits our effectiveness by spreading our sub-specialist workforce across multiple sites and reducing opportunities for effective multidisciplinary team working.
· Workforce – operationally providing complete and comprehensive services that directly mirror each other on both sites is a significant workforce challenge, exacerbated by subspecialisation, and further complicated by difficulties with recruitment and retention of the workforce.
· The national Getting It Right First Time (GIRFT)[2] programme reviewed the cardiology service in November 2019. It was recommended that:
o All inpatient cardiology activity consolidated onto a single site. Non-invasive investigations and outpatients should be provided on both sites subject to appropriate infrastructure and sufficient volumes of activity.
o Percutaneous Coronary Intervention (PCI) activity at Eastbourne District General Hospital falls short of meeting British Cardiovascular Intervention Society (BCIS) criteria for minimum institutional volumes, and individual numbers of procedures for some operators on both sites are below the minimum of 75 cases per year. Coupled with a low volume alternating Primary Percutaneous Coronary Intervention (PPCI) service at both sites, this arrangement is not sustainable in the longer term and the Trust should aim to consolidate all Percutaneous Coronary Intervention activity on a single site. The number of operators should be reviewed to ensure that all are performing at least 75 procedures per year.
o Volumes of Chronic Total Occlusion (CTO) are low across the Trust and should be consolidated on one site. The Trust should review the long-term sustainability of the service if volumes do not increase.
o The volume of complex devices at the Conquest site is well below the British Heart Rhythm Society (BHRS) recommended minimum activity levels and device implants should be consolidated on one site. This will also allow for more effective management of device related emergencies.
o The Trust should aim to provide 7-day echo cover at both sites.
· Quality: performance indicators and national guidance. There are a range of performance indicators and national guidance for cardiology care, that East Sussex Healthcare Trust is not currently able to consistently meet all of these due to the service’s current configurations.
· Nationally, what does the future of cardiology services look like?
o medical advancements in research and technology are reshaping the way in which we will deliver cardiology care in the future. Increasing subspecialisation, means that cardiologists now specialise in one or two types of treatment, rather than offering the full range, along with the development of new technologies, diagnostics and treatment options. These modernising changes reduce risk, pain and infection, and allow patients to recover more quickly, which means that many planned procedures are now done safely as day-cases, without having to stay overnight in hospital.
o Evidence, from other areas of the country where a “front door” cardiac assessment model has been implemented, has shown that early cardiac specialist involvement in a patient’s care can lead to early and effective patient management, timely patient care and avoids admission to hospital, therefore improving patient experience. The evidence also suggests a discharge rate of 30-40%, meaning 30-40% of patients can go home the same day as they present due to a quick and efficient service providing the care they need. This thereby makes the best use of the workforce and bed availability.
· 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.
· IT / Digital: it has been recognised that improvements to the digital infrastructure can benefit and support patient pathways.
· Estates and equipment: the engineering infrastructure is no longer fit for purpose, some of the catheterisation labs are due for replacement and are not operating reliably.
· 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 limited range of acute cardiology 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 behind the need for the current service to change. This provided the basis for our engagement with local people, clinicians and other professionals to further understand what is important to them about cardiology services. This engagement has indicated several key themes:
· Care provided
· Equality and diversity
· Access and transport
· Clinical services.
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 Inequalities Assessment).
Following pre-consultation engagement, three options development and appraisal workshops (independently chaired and facilitated by Opinion Research Services[3]) took place, during March 2021, to identify and consider a longlist of possible options for the future provision of acute cardiology 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 Inequality 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.[4]
· We have developed our proposal and associated consultation plans in line with the Gunning Principles[5] 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 the most specialist cardiac services, needed by a small number of patients, at one of our two acute hospitals and form a Cardiac Response Team to support patients on their arrival at A&E, alongside ‘hot clinics’ that will provide consultant-led rapid assessment at both of our acute hospital sites.
These specialist cardiac services include surgical procedures or investigations that might require an overnight or longer stay in hospital. The introduction of this front door model and hot clinics will ensure faster diagnosis, reduce waiting times, reduce the number of appointments required for patients and reduce the length of time patients have to stay in hospital. These are key quality improvements to the cardiology service.
We are not proposing to change the vast majority of our services, so there will still be cardiology care for anyone who needs it. To make sure that the majority of patients receive good quality care close to home, outpatients, non-invasive diagnostics, cardiac monitored beds, cardiac rehabilitation and heart failure services will stay at both hospitals or in the community. For the many patients who are referred to a consultant by their GP (for non-urgent cases) they will continue to be seen in outpatient clinics, which will still be provided at both hospitals and some clinics in the community.
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 (HOSC). 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 acute cardiology 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 engagement and the options appraisal is a proposal to take forward two options for formal consultation with patients, the public and local stakeholders:
· Option 5a: Co-locating all catheterisation laboratories and specialist cardiology inpatient services from Eastbourne District General Hospital, with acute outpatients and diagnostic services remaining at both sites; alongside establishment of Cardiac Response Team in A&E and hot clinics providing rapid assessment at both our acute hospital sites.
· Option 5b: Co-locating all catheterisation laboratories and specialist cardiology inpatient services from Conquest Hospital, with acute outpatients and diagnostic services remaining at both sites; alongside establishment of Cardiac Response Team in A&E and hot clinics providing rapid assessment at both our acute hospital sites.
The proposed transformation, with the front door model, will make key quality improvements to the service, such as:
· change the general medical model to ensure faster access to an expert opinion at the “front door” which will improve care, recovery of services impacted by Covid-19, East Sussex Health Trust’s performance and outcomes for our patients; reducing the waiting time for patients, and the amount of time patients have to stay in hospital.
· allow for the creation of flexible and resilient rotas, which in turn enables the workforce to provide front-end assessments (clinical assessments at the “front-end” of the patient pathway, when they arrive in A&E), through the introduction of a new cardiac response team and establishment of hot clinics, all of which are integral to realising the benefits inherent in the proposed model.
· enable East Sussex Healthcare NHS Trust to more sustainably achieve service standards and ensure that local people now and into the future have access to the best possible care we can offer.
Evidence, from other areas of the country where a “front door” cardiac assessment model has been implemented, has shown that early cardiac specialist involvement in a patient’s care can lead to early and effective patient management, timely patient care and avoids admission to hospital, therefore improving patient experience. The evidence also suggests a discharge rate of 30-40%, meaning 30-40% of patients can go home the same day as they present due to a quick and efficient service providing the care they need; enabling the best use of our staff and services.
These options 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 recognise that both of these options 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 proposals. All new information and evidence gathered as part of a consultation will inform a decision on the model of delivery and the site of delivery for the specialist aspect of the service.
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.