Report to:	East Sussex Health Overview and Scrutiny Committee (HOSC)
Date of meeting:	2 December 2021
By:	Assistant Chief Executive
Title:	Reconfiguration of Cardiology Services at Maidstone and Tunbridge Wells NHS Trust (MTW)
Purpose:	To update HOSC on proposals to redesign cardiology services at MTW

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RECOMMENDATIONS

The Committee is recommended to:

1. Consider whether the service change proposals relating to Maidstone and Tunbridge Wells NHS Trust (MTW)  cardiology services set out in Appendix 1 constitute a ‘substantial variation’ to health service provision requiring statutory consultation with HOSC under health scrutiny legislation.

2. Agree that, if the proposals are a substantial variation to services, HOSC will undertake a detailed review of the proposals in order to prepare a report and recommendations.

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1. Background

1.1. Maidstone and Tunbridge Wells NHS Trust (MTW) provides acute cardiology services from both Tunbridge Wells Hospital and Maidstone Hospital.

1.2. In July 2021 the Kent HOSC received a report outlining the proposals to reconfigure MTW’s cardiology services and agreed that they did not constitute a substantial variation to services and so did not require formal consultation with that Committee.

1.3. Kent and Medway Clinical Commissioning Group (CCG) and MTW are in the process of running a 12-week public engagement exercise on the proposals to consolidate services onto a single site that is due to end 14^th January 2022.

1.4. Patients living in the north of East Sussex will also be affected by the proposals and it is therefore necessary for the East Sussex HOSC to consider whether the proposals constitute a substantial variation to services requiring formal consultation with the Committee alongside and separately to the public engagement.

2. Supporting information

Proposals for cardiology services

2.1. The report from the Kent and Medway CCG and MTW attached as Appendix 1 sets out their proposals for the transformation of acute cardiology services provided by MTW.  

2.2. Cardiology is the branch of medicine dealing with the diagnosis and treatment of heart disorders and related conditions.  While there are many clinical conditions that can affect the heart in people of all ages, many heart conditions are age-related, making cardiology services more and more important as people get older. Cardiology is also constantly evolving with new developments in disease prevention, diagnostics and therapeutics.

2.3. Both of MTW’s hospital sites have cardiac catheter laboratories, but both only provide a partial inpatient cardiology service; Tunbridge Wells Hospital provides angioplasty intervention and simple pacing procedures, whilst Maidstone Hospital provides simple & complex cardiac pacing and electrophysiological intervention. On this basis if patients at Maidstone hospital require an angioplasty intervention, they will be transferred to Tunbridge Wells Hospital; similarly, if patients at Tunbridge Wells Hospital require complex cardiac pacing or electrophysiological intervention, they will be transferred to Maidstone Hospital.

2.4. Both sites have a 6 bedded Coronary Care Unit (CCU), and patients’ inpatient stays outside of CCU are managed in the general medical wards with some sub specialisation. Both sites have Outpatients and other diagnostics (electrocardiogram, echocardiography).

2.5. The CCGand MTW argue this arrangement is unsustainable because:

· patients are having their treatment delayed due to requiring transfers between the two hospital sites for procedures during their inpatient stay;

· there is an inability to provide specialist cardiology services in a dedicated cardiology ward outside of CCU at either site;

· it causes diluted services due to necessary duplication across two sites;

· there is difficulty in recruiting and retaining specialist staff of all disciplines; and

· the Trust has non-compliance with 9 of 25 clinical standards set out in the National Getting it Right First Time (GIRFT) report 2020.

2.6. As a result, the CCG and MTW are proposing the following changes:

• Inpatient cardiology services would be centralised onto one ‘hot site’ providing 12 CCU bed; 2 co-located cardiac catheter labs for both elective and emergency procedures; up to 24 dedicated cardiology beds; consolidated skills and facilities onto one site for the provision of care to the most complex cardiology conditions; and consolidation of lab staff to one site facilitates meaning provision of 24/7 on call and weekend lab activity.
• The ‘cold’ site would continue to manage less complex or serious cardiology conditions through the medical ward with support from the cardiologists.
• Outpatient clinics and non-invasive investigations (ECG, echocardiograms) will remain on both sites and provision of specialist outpatient clinics at both sites (for example heart failure and arrhythmia clinics).
• A robust transfer protocol will ensure patients on the ‘cold’ site are managed safely, quickly and appropriately for their condition.

2.7. The CCG and MTW began a 12-week engagement period on 22^nd October 2021 running until 14 January 2022. The engagement document is attached at Appendix 2 and contains four options for cardiology services:

Option 1: Do nothing. Leave services as they are

Option 2: Consolidate specialist inpatient and cardiac catheter lab services at Maidstone Hospital by reconfiguring existing space (preferred option of the CCG/MTW)

Option 3: Consolidate specialist inpatient and cardiac catheter lab services at Tunbridge Wells Hospital by reconfiguring existing space

Option 4: Consolidate specialist inpatient and cardiac catheter lab services at Maidstone Hospital by building a new space and reconfiguring existing space.

2.8. The CCG and MTW says the benefits of these proposals include:

• 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; and
• the ability to develop the service and provide even more specialist cardiology services for MTW’s catchment population in the future, in line with the Trust’s clinical strategy.

2.9. The majority of patients using MTW cardiology services live in Kent, however, around 10% of patients are from East Sussex:

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

2.10. For patients living in East Sussex, the majority of the activity is at Tunbridge Wells Hospital, and most of the activity is outpatients, with 61 non-elective admissions in 2020/21.

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

2.11. Kent HOSC considered these proposals in July 2021 and agreed that whilst they were significant, they were not substantial and so concluded there was not a requirement for the CCG to consult with that Committee.

HOSC role

2.12. Under health scrutiny legislation, NHS organisations are required to consult affected HOSCs about a proposed service change that would constitute a ‘substantial development or variation’ to services for the residents of the HOSC area.

2.13. There is no national definition of what constitutes a ‘substantial’ change. Factors such as the number or proportion of patients affected; whether the service provides planned care (outpatient appointments or day case surgery) where patients and carers make arrangements for travel beforehand or un-planned care (emergency and urgent care) where patients may be admitted via ambulance or travel to an Emergency Department; the level of improvement offered by the new service; and the availability of alternative services nearby are often taken into account in coming to an agreement between the HOSC and the NHS on whether formal consultation is required.

2.14. If HOSC agrees that the confirmed proposals do constitute a substantial change, the Committee will need to consider the plans in detail in order to respond to the CCG with a report and recommendations. The Committee may wish to consider how it would undertake this task, which could be through establishing a Review Board to conduct a review on behalf of the full HOSC, with the Committee agreeing any recommendations before they are submitted to the NHS.

2.15. Where the HOSC does not consider a proposal to be a substantial variation to services there are alternative options for further scrutiny work including submitting a written response to the public engagement, informal HOSC board meetings to scrutinise the proposals in more detail, and further reports to the Committee as the proposals are agreed and implemented.

3. Conclusion and reasons for recommendations

3.1. This report presents HOSC with proposals for the development of cardiology services in MTW, in particular the proposal to centralise inpatient cardiology services onto one ‘hot site’ and retain a number of other services on the ‘cold site’.

3.2. The Committee is recommended to consider whether the service change proposals set out in Appendix 1 constitute a ‘substantial variation’ to health service provision requiring statutory consultation with HOSC; and if so, to agree to undertake a detailed review of the proposals.

PHILIP BAKER
Assistant Chief Executive

Contact Officer: Harvey Winder, Policy and Scrutiny Officer

Tel. No. 01273 481796

Email: harvey.winder@eastsussex.gov.uk