Decision Making Business Case Summary for Cardiology Transformation at East Sussex Healthcare NHS Trust

 

1      Context

1.1      NHS Sussex works in partnership with health and care organisations across Sussex as part of our Integrated Care System. Our aim is to ensure better health and care for all now and in the future.  Our ambition is for every person living in Sussex to have access to the best health and care from the moment they are born and throughout their lives. We want:

·         People to live for longer in good health.

·         To reduce the gap in life expectancy between people living in the most and least disadvantaged communities.

·         People’s experience of using services to be better.

·         Staff to feel supported and work in a way that makes the most of their dedication, skills and professionalism.

·         The cost of care to be affordable and sustainable in the long term.

1.2      Our proposals sit within this context and focus on the improvement of hospital-based cardiology services to benefit our population in East Sussex. We want to ensure sustainable services into the future.  This means that there is a focus on expanding services within local communities and recognising that for some of our more specialist services, consolidating these in one place will ensure the retention of this specialist expertise within East Sussex in a way that offers the best outcomes for local people. Our commitment to two thriving district general hospital sites, both with Emergency Departments (EDs) and a wide range of services, is supported by specialist services at one or other site in order to deliver the best outcomes for patients.

East Sussex Healthcare NHS Trust Services

1.3      East Sussex Healthcare NHS Trust has made significant improvements for patients and local residents in recent years. The Trust is rated ‘good’ by the CQC, with several ‘outstanding’ services and has ambitious plans for the future, enabling residents to access the best care in the most appropriate place: at home; in the community; or when they need to come into hospital.

1.4      As an integrated acute and community provider, an important part of the trust’s five-year strategy to best meet the healthcare needs of our population is to increase and improve the care provided outside of hospital. This means being proactive in supporting the health of local residents, preventing avoidable hospital visits and stays, improving patient outcomes and experience and making better use of resources. This has helped the Trust to focus their hospitals to build on their strengths while improving how services work together across the whole health and care system.

1.5      The Trust has two acute hospital sites, Conquest Hospital in Hastings and Eastbourne District General Hospital. Both the Conquest and Eastbourne District General acute hospital sites provide urgent and emergency services, with some services already located solely or primarily at one or other of these sites. The Trust also operates services at Bexhill Hospital. Bexhill Hospital is a community-based facility with an emphasis on ophthalmology and rehabilitation services. 

1.6      Eastbourne District General Hospital looks after serious stroke cases, ear nose and throat inpatients and is also home to the Trust’s urology service, for which we have recently invested in a dedicated investigation suite, robotic surgery and non-invasive treatment for kidney stones. The hospital also provides for patients needing inpatient diabetes care, day case eye surgery (undertaken in the Jubilee Eye Suite) and a diabetic foot service. In addition, inpatient endocrinology beds are only at Eastbourne District General Hospital.

1.7      The Conquest Hospital in Hastings is the Trust’s trauma unit and looks after emergency surgical services and complex elective surgical services, including general, vascular, gynaecology and orthopaedic surgery, and patients needing closer medical monitoring and support when giving birth. The hospital also includes paediatric inpatient services.

1.8      Both hospitals are supported by a range of clinical support services, operate 24/7 emergency departments and intensive care units (ITUs).

1.9      There is a commitment to improving hospital services at both acute sites, Conquest Hospital and Eastbourne District General Hospital. As detailed above, each hospital site has its own profile of services, and we are working to strengthen and develop these two hospitals to make best use of the resources at each site to best serve our patients; having two thriving acute hospital sites is central to this plan.

1.10   Looking further ahead, the trust’s Building for our Future programme, funded as part of the government’s commitment to build 40 new hospitals, will deliver a complete redesign of both our ageing hospitals, taking advantage of new technologies and improvements in healthcare to ensure that we can meet the future needs of our population.

 

2      Introduction

2.1      The purpose of the Decision-Making Business Case is to describe the final proposals to provide a model of care that will improve the cardiology services, their sustainability, and outcomes for the benefit of the local population. It describes the evidence base, the process for the development of the proposals, quality and equality impact assessment and details key enablers such as workforce and finance.

2.2      This summary also describes the wide engagement to date, including the public consultation, and the processes East Sussex Healthcare NHS Trust and NHS Sussex have followed in developing proposals, ensuring clinical assurance of the model, seeking wide engagement and feedback, and finalising proposals for decision-making.

2.3      The full Decision-Making Business Case has been published and is available to all committee members on request. The Decision-Making Business Case is available here. It recommends one option to take forward for implementation, which, has been approved by the NHS Sussex Integrated Care Board, and is now submitted to the East Sussex Health Overview Scrutiny Committee for their consideration.

2.4      The Decision-Making Business Case follows the approved Pre-Consultation Business Case and subsequent formal public consultation and shows how all available information and evidence has been considered, together with feedback captured from the public consultation. This has informed the final proposal to transform acute cardiology services that has been developed by NHS Sussex, in partnership with the East Sussex Healthcare NHS Trust (ESHT). Subject to the outcome of the East Sussex Health Overview and Scrutiny Committee, mobilisation of the transformation proposal can begin for implementation within the timeframe outlined, by January-March 2025.  Early implementation of some elements of the model may be sooner than this, in order to realise quality benefits as quickly as possible.

2.5      The document provides a summary of the context and of the case for change as outlined in the Pre-Consultation Business Case. It also provides an analysis of the feedback received from the public consultation and the consultation with the East Sussex Health Overview and Scrutiny Committee, and the updated post-consultation proposal, approved by NHS Sussex,  that has been informed by the feedback received from local people and stakeholders during the consultation process.

2.6      A significant majority of respondents to the public consultation agreed with the proposal and views differed on which site should be preferred for the delivery of the most specialist services.  NHS Sussex recognises the importance of access to services and has carefully and systematically analysed the consultation outcomes and balanced it with evidence that has been collected since the Pre-Consultation Business Case and in response to the consultation. This process informed NHS Sussex’s considerations during the Decision-Making Business Case development process in order to ensure consultation feedback informed final proposals.

2.7      The model of care has been confirmed throughout the process as the right strategic proposal to improve acute cardiology services and outcomes for the local population and is supported by stakeholders across local communities. It remains unchanged from the previously approved pre-consultation business case. 

2.8      The proposed model of care is that improvements would be made to services for all local people with the development of cardiac response teams on both sites. In addition to this, the specialist interventional services, would be located on one of the two acute sites.  The carefully considered assessment of this through an independently facilitated site panel, has concluded that the proposed site should be Eastbourne District General Hospital.

2.9      The model is based on clinical best practice and national guidance and evidence, including British Cardiovascular Intervention Society, Heart Rhythm UK, National Institute for Cardiovascular Outcomes Research, the national Getting It Right First Time programme and NHS contract for specialist cardiology. Alongside local clinical engagement and leadership in the development of the model of care, it has also been reviewed by the South East Clinical Senate.

2.10   The Cardiac Response Teams in the Emergency Departments and hot clinics on both sites will provide real benefits for patients in terms of faster senior decision making, faster access to diagnostics, faster cardiology management and treatment plans, less appointments and reduced waiting times, and better patient experience and outcomes.

2.11   Alongside this, proposed specialist interventional services provision from one site supports the Trust to follow, and sustain, national guidance which recommends minimum numbers of procedures to be undertaken by clinicians to increase specialist expertise and therefore improve patient outcomes.

2.12   For those people requiring emergency specialist interventional services, it is common to travel by ambulance to a specialist unit.  For example, in West Sussex patients are well served by hospitals in Brighton or Portsmouth for specialist emergency interventional cardiology.

2.13   In summary, the proposal approved by NHS Sussex, is to improve the services at both acute hospital sites through forming a Cardiac Response Team to support patients on their arrival at the Emergency Department (ED), alongside “hot clinics” that will provide consultant-led rapid assessment at both of our acute hospital sites and locate the most specialist cardiac services, needed by a small number of patients, at Eastbourne District General Hospital. These elements are interdependent as locating the specialist service on one site also enables resource to be focused on enhancing the front door offer at both sites.  

2.14   The introduction this model, with a Cardiac Response Team in ED, together with hot clinics will ensure faster senior clinical input, faster assessment, treatment and diagnostics, reduced waiting times, more procedures being completed on an outpatient basis (at both sites), a higher proportion of elective procedures completed as day cases (and therefore fewer overnight stays), and fewer repeat outpatient visits.

2.15   The changes to services as a result of the proposals are summarised below:

Services that would be new to both sites

·         Cardiac Response teams which will provide all front-end care, including cardiac triage, assessment, diagnostics (including radiology and pathology), prescribing, treatment and onward referral, if required. This change, from the current model of care, is that this would all be completed on the patient’s arrival to ED, rather than later in the patient’s pathway as is the process at present. This means patients will receive a faster diagnosis, reduced waiting times, reduced number of appointments required for patients and a reduced length of time patients have to stay in hospital.

·         Hot clinics that will provide patients with consultant-led rapid assessment, which will also 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.

·         Some day-case procedures will be able to be completed as an outpatient procedure, rather than as an inpatient, and these will also be available from both acute sites along with all other outpatient appointments.

 

Services that would remain on both sites

·         Outpatient services will continue to be provided at both sites, this includes new patients, follow up and monitoring appointments, treatment plan appointments and discussions, pre-surgical assessment and post-surgical follow up, and diagnostic services. There are approximately 50,000 appointments per year for these outpatient services.

·         Cardiac monitoring will continue to be available at both sites, as cardiac monitors are available in multiple areas and services, not just within cardiology. The emergency department and the acute medical units / acute assessment units all have cardiac monitored beds, which will continue to be available at both sites.

 

Services that would change and be co-located to one acute site

·         The most specialist cardiology services, which will be co-located at Eastbourne District General Hospital, and supports approximately 3,000 patients per year, including those who require catheterisation laboratories, Coronary Care Unit and cardiology inpatient beds. This would mean approximately 1,500 patients, who would have previously attended Conquest Hospital for these services, would now have their treatment provided at Eastbourne District General Hospital.

2.16   This proposal will have positive impacts for our patients improving patient experience, patient outcomes and our performance against national standards in the long term, whilst making the service more efficient and sustainable for the future, alongside positive impact for our workforce now and in the future. Our proposal to introduce Cardiac Response Teams and rapid assessment hot clinics will positively impact all cardiology patients across both hospital sites. Approximately 1,500 patients who would have previously attended Conquest Hospital for the most specialist cardiology services, will now have their treatment provided at Eastbourne District General Hospital, these patients will be variably impacted by these proposals depending on where they live, whether they are accessing the service on an emergency or planned basis and their mode of transport informed by clinical advice.

2.17   The evolution of the Covid-19 pandemic required East Sussex Healthcare NHS Trust to take steps to increase its critical care capacity during the summer months of 2020. As part of this, cardiology facilities at the Conquest Hospital were identified as required to support the response to the pandemic; meaning that the Conquest Cardiac Catheter Labs were unable to be used for cardiology procedures. The interventional service therefore had to be temporarily consolidated to Eastbourne District General Hospital.

2.18   As part of the temporary change to services due to the Covid-19 pandemic, cardiology services were also able to test out a front-end model of care in the Emergency Department; where senior clinicians were able to provide assessment and opinion to patients presenting to ED. This enabled the service to provide more timely access to expert opinion, appropriate diagnostics, and treatment; in many cases reducing the need for admission whilst also improving the quality of care received. From this perspective of cardiology service provision, the change in provision of interventional services demonstrated the associated benefits of a front-end model.

3      Considerations

3.1      The Case for Change was developed by a wide range of stakeholders including clinicians, operational staff and experts by experience. It was recognised that the current service is unsustainable. We have reviewed the strategic drivers for change and the existing acute cardiology 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 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 that does not maximise the opportunities of subspecialisation and is further complicated by difficulties with recruitment and retention of the workforce. For example, East Sussex Healthcare NHS Trust’s vacancy rate for specialist staff is between 10-15% (many staff work across both sites).

·         Quality - performance indicators and national guidance. There are a range of performance indicators and national guidance for cardiology care, but East Sussex Healthcare NHS Trust is not currently able to consistently meet all of these due to the service’s current configurations.

·         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.

·         The national Getting It Right First Time (GIRFT)[1] programme reviewed the cardiology service in November 2019 making a range of recommendations including consolidating inpatient cardiology, ensuring clinicians are performing the right numbers of procedures to ensure clinical quality.

3.2      The case also considered the national picture and what the future of cardiology services looks like. This includes medical advancements in research and technology that are reshaping the way in which we will deliver cardiology care. 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.

3.3      As a result, the Decision-Making Business Case proposed changes to a range of acute cardiology services provided by East Sussex Healthcare NHS Trust.

4      Process to date

Our Case for Change and developing our Pre-Consultation Business Case

4.1      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 cardiology services. This initial engagement indicated several key themes as important to local people:

·         Care provided

·         Equality and diversity

·         Access and transport

·         Clinical services.

4.2      Alongside finding out what is important to local people and clinicians, we reviewed local health needs in East Sussex. This told us that there are some groups of local people who have particular needs and may be disadvantaged in accessing current services. We took account of these needs in our proposals and sought to mitigate those disadvantages through the proposals outlined in the Pre-Consultation Business Case (more detail on this can be found in the Decision-Making Business Case: Appendix 1 – Equality and Health Inequalities Impact Assessment and Appendix 2 – Equality and Health Inequalities Impact Assessment Actions). The full Equality and Health Inequalities Impact Assessment is available here.

4.3      Following pre-consultation engagement, three options development and appraisal workshops (independently chaired and facilitated by Opinion Research Services – ORS^[2]) took place, during March 2021, to identify and consider a longlist of possible options for the future provision of acute cardiology services, including sites where the service would be delivered from, to appraise these options and make recommendations for preferred viable options.

4.4      Following this, and as part of our in-depth comparative analyses for the Pre-Consultation Business Case, we 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.

4.5      A Pre-Consultation Business Case was developed to make the case for change and set out the plans for a Public Consultation around the transformation of acute cardiology services at East Sussex Healthcare NHS Trust. It was approved by East Sussex CCG and East Sussex Healthcare NHS Trust, on 17 and 30 November 2021 respectively, and submitted to the East Sussex Health Overview and Scrutiny Committee on 2 December 2021 prior to formal public consultation. An independent report on the findings of the consultation has been produced and this report presents the feedback from those who participated in the consultation. This is found at Appendix 3 of the Decision-Making Business Case.

4.6      When developing our options, our final draft proposals, the Pre-consultation Business Case and Decision-Making Business Case we considered insight from local people and clinicians from engagement and consultation; continually assessed our developing proposals in relation to equality, health inequality and quality impact and took associated action: commissioned independent travel analysis; took account of South East Clinical Senate recommendations; were informed by feedback from East Sussex Health Overview and Scrutiny Committee; assessed proposals against the NHS Four Tests for service reconfigurations ; undertook stage one and two NHSEI assurance; and developed our proposals and associated plans in line with the Gunning Principles.

4.7      The Joint Sussex Committee reviewed the summary PCBC, together with the Equality and Health Inequalities Impact Assessment and Quality Impact Assessment and approved the case for consideration by the East Sussex Health Overview and Scrutiny Committee, following which (on 2 December 2021) East Sussex Health Overview and Scrutiny Committee reviewed the summary PCBC, together with the Equality and Health Inequalities Impact Assessment and Quality Impact Assessment and considered the proposal to be a substantial variation, and therefore asked that the programme consulted with East Sussex Health Overview and Scrutiny Committee.

Public Consultation

4.8      The formal public consultation into the proposal to transform cardiology services at East Sussex Healthcare NHS Trust began on 6 December 2021 and ended on 11 March 2022. It set out the quality improvements anticipated from the proposed transformation, together with information about the two possible sites for specialist services. Opinion Research Services (ORS), was appointed to advise on, independently manage and report on the public consultation programme of engagement with service users, their families and carers, clinicians and other NHS staff and other stakeholders. The Public Consultation Feedback Analysis report outlined that our consultation was open, accessible, and following ‘good practice’ guidelines in both the scale and the balance of elements used, and that we took appropriate action to ensure any potential impacts of the COVID-19 pandemic were mitigated throughout undertaking the consultation process. The full report can be found as an appendix to the Decision-Making Business Case at Appendix 3. The public consultation was well promoted and included virtual public meetings, stakeholder events and face-to-face listening events, and included a wide range of activities including a focus on groups identified by the Equality and Health Inequalities Impact Assessment.

4.9      A number of common themes were identified during the public consultation process. These included:

·         Travel and access, for example:

o   Older people and people with disabilities, severe clinical needs, multiple complex needs, young children, among others

o   Those from more rural areas and those on lower incomes who might have to pay for taxis to access services

o   Anyone without access to private transport, or who finds long journeys challenging or distressing

o   Staff members who have to travel further or face increased costs, which could impact their well-being

·         Staff recruitment and retention, and/or job security especially at non-specialist site

·         Impacts on other services, for example. South East Coast Ambulance Service (SECAmb), and concerns about infrastructure and patient transport

·         Implications for cardiology patient care on other wards, for example monitoring equipment

Key actions following public consultation

4.10   Alongside public consultation, East Sussex HOSC established a Review Board to carry out a detailed review of the proposals and produce a report and recommendations on behalf of the Committee. In addition, following feedback from the public consultation regarding travel and access, we established a Travel and Transport Review Group to review our developing proposals and make recommendations.  The feedback from the HOSC Review Board and the Travel and Transport Group are outlined below, followed by the recommendations and associated planned action.

Engagement with East Sussex Health Overview and Scrutiny Committee (HOSC) – HOSC Review Board

4.11   The Review Board carried out its review between April and June 2022. A full report (Appendix 4 of the Decision Making Business Case) sets out the evidence the Board considered, along with its conclusions and recommendations. The HOSC review board report is available here and the travel and transport review group report is available here. The East Sussex HOSC was presented with the Review Board’s report, findings and recommendations at their meeting on 30 June 2022, where it was approved by the membership. The recommendations made by the East Sussex HOSC were as follows:

4.12   The Committee endorsed the proposed new clinical model for cardiology on 30 June 2022, including:

·         Cardiology catheter labs should be single-sited;

·         That both Eastbourne District General Hospital and Conquest Hospital sites are viable sites;

·         There is potential for new services to improve patient care and outcomes via the ‘Front Door’ model and ‘Hot Clinics’;

·         There will be better services for patients at either Emergency Department (ED) sites; and

·         Other services provided at each of the hospitals will not be affected or downgraded by the proposals for cardiology

4.13   The Health Overview and Scrutiny Committee Review Board carefully considered a range of evidence on the proposals for the reconfiguration of cardiology services in East Sussex and agreed the clinical case for change is sound and addresses the staffing challenges and future sustainability of specialist interventional cardiology services. The HOSC Review Board acknowledged that members of the public may ideally wish to see interventional services retained at both acute hospitals, but it would be in patients’ best interests if such services continue to be provided in East Sussex at whichever hospital is selected. There are clear patient benefits arising from the ‘Front Door’ cardiac responses teams in Emergency Departments and ‘Hot Clinic’ models and the HOSC Review Board advised they would like to see these proposals implemented as soon as possible.

4.14   On balance, the HOSC Review Board considered the clinical considerations, patient benefits and the need to address staffing challenges, outweigh any disbenefits of the proposals in terms of increased travel. It was also considered important that access is taken into account in the development of the Decision-Making Business Case and throughout the implementation of the proposals.  As part of their review, the HOSC Review Board made a series of recommendations, the key ones of which are summarised in section 4.23.

4.15   These recommendations have been taken into account and further details on how these have been considered and addressed, for our post-consultation proposal and as part of the development of the Decision-Making Business Case, can be found in section 8 of the Decision Making Business Case.

4.16   At this stage, initial actions in response to insight from the public consultation included a review and update of the Quality Impact Assessment, Equality and Health Inequalities Impact Assessment, as well as updating of previous Equality Health Impact Assessment actions, and the establishment of a Travel and Transport Review Group.

Travel and Transport Review Group

4.17   During the public consultation, travel and transport (public and private transport, including access and parking) were raised by many respondents as issues to be addressed. Therefore, we established a Transport and Travel Review Group to consider the issues raised.

4.18   The group was tasked with reviewing findings from the pre-consultation engagement processes, options development and appraisal processes, Equality and Health Inequalities Impact Assessment (Equality and Health Inequalities Impact Assessment), the Public Consultation, as well as independent travel analysis carried out by external consultants, and considering the conclusions to make suggestions and recommendations on possible transport solutions for those who may be affected by the proposed service change.

4.19   People responding to the consultation identified key groups who may be adversely affected by transport and travel impacts created by the proposals, e.g. some people having to travel further to see their loved ones and some staff having longer journeys to work. Alongside this, respondents made some suggestions, e.g. to work with authorities in relation to public transport, consider parking, consider financial reimbursement. 

4.20   Following the review outlined above including insight from the public consultation, the Travel and Transport Review Group made several recommendations some for implementation and some for further investigation.  The key actions are summarised in 4.23.

Recommendations and associated action/action plans from HOSC Review Board and Travel and Transport Review Group

4.21   The Health Overview and Scrutiny Committee Review Board and the Travel and Transport Group made a range of recommendations which have been taken into account in our final proposal and our developing draft mobilisation planning.

4.22   These key recommendations were focused on travel and transport and included providing travel support for local people; the introduction of Travel Liaison Officer at East Sussex Healthcare NHS Trust; improved communication about travel options; liaising with patients about their individual travel and access needs; supporting patients with information and processes about accessing financial reimbursement where eligible; improving information for patients about alternative transport options and exploring over the longer-term improvements to public transport; and measures to support recruitment and retention of staff.

4.23   In response to these recommendations, some have been implemented and others have been committed to and we are progressing them as this programme continues and we implement our proposals. A summary is provided below:

·         The priority recommendation of the establishment of a travel and transport liaison officer has been committed to by the Trust and will be implemented alongside these proposals

·         Work has taken place within the Trust to ensure information provided via its website, patient letters and patient information leaflets is clear for patients around travel, transport and access options and parking to it various sites. This work will continue to be reviewed and updated as additional actions and recommendations are addressed

·         Work has taken place to ensure staff are aware of travel opportunities, such as Trust schemes, are promoted and this will be included in staff messages on a frequent basis

·         Work has taken place with ICS colleagues to understand learning around travel arrangements for the recent vaccination programme

·         A commitment has been made to monitor staff recruitment and retention measures and these have been included in the Key Performance Indicators (KPIs) of this programme

·         As part of the upcoming communications plan, post decision, further work will take place to ensure information around the changes will be shared with our local stakeholder and population, including a Frequently Asked Questions document

·         Working with Trust and primary care colleagues to ensure individual needs of patients are recognised and taken account of when booking appointment and procedures, along with clear communications to patients to raise awareness of the options available to them

·         Work is in progress to compile a directory of any, and all, transport services, including community, volunteer and charity organised services, and their eligibility criteria where necessary, to which patients could be signposted

·         Work with voluntary, community and social enterprise and patient representatives to ensure changes to services and facilities is co-designed

·         Consideration by the Trust of a long-term travel and transport strategy

4.24   There are also a number of recommendations which are being explored by the wider Sussex system, as these do not solely relate to cardiology patients who attend East Sussex Healthcare NHS Trust, such as:

·         Exploring the options for a pilot shuttle bus service

·         Working with NHS colleagues on additions to the Non-Emergency Transport Service (NEPTS), such as a digital tracking element and eligibility criteria

·         Working with local authority and public transport providers on and potential future services

 

A summary of the recommendations of the HOSC Review Board and the Travel and Transport Group and progress against these is provided at Annex 1 to this report.

4.25   Considering options and developing a preferred site for specialist cardiology

Appraisal on preferred site

4.26   Our Pre-Consultation Business Case (PCBC) outlined our intention to consult on the proposed model, alongside proposed sites for the specialist service as there was no significant information or evidence at that stage that would indicate a site preference for these. We were clear we would assess and recommend a decision based on the range of published information and evidence, together with feedback from the public consultation, any further information following publication of the PCBC and required further analysis. 

4.27   This information would be used to assess each of the site options against weighted criteria that considered information from our Pre-Consultation Business Case, Equality and Health Inequality Impact Assessment, Quality Impact Assessment, and new or updated information since the public consultation. It was recognised that there will be differential impacts, benefits and risks associated with each site option.

Independently facilitated site panel

4.28   On 12 September 2022, following the close of the public consultation and the completion of analysis of consultation feedback, NHS Sussex convened an independently facilitated site panel to consider the two possible locations, Conquest Hospital in Hastings and Eastbourne District General Hospital, and to undertake an appraisal exercise aligned to five key criteria, listed below, and a number of sub-criteria that took into account issues such as population demographics, health inequalities, travel times, workforce issues, infrastructure on sites activity and finance. This is not intended as an exhaustive list, the full report from the independently facilitated site panel is contained in the report from Opinion Research Services (ORS) which is attached to the Decision Making Business Case at Appendix 7.

·         Quality and Safety

·         Clinical Sustainability

·         Access and Choice

·         Deliverability

·         Financial Sustainability

4.29   The purpose of the panel was to gather views from key stakeholders on the available evidence to inform a site preference. The outcome was not, on its own, a decision on site for the location of specialist cardiology inpatient services and catheter laboratories in East Sussex.  The outcome was then reviewed alongside evidence regarding clinical quality and sustainably, public health analysis, detailed financial analysis, speed of implementation, and alignment with the travel and access analysis in order to test this preference. The panel included a variety of different stakeholders to consider and discuss the evidence, provide insight and undertake indicative scoring. The stakeholders represented a balance of attendees, particularly in terms of those attendees with a strong connection to just one or other of the sites, and included:

·         Patient representatives and service users

·         Voluntary, community and social enterprise organisation representatives

·         Cardiology service staff, including consultants, nurses and junior doctors

·         Clinicians from other services, such as anaesthetics, physiology, radiology

·         GP Clinical Lead

·         Healthwatch

·         NHS Sussex and East Sussex Healthcare NHS Trust Managers, such as senior quality, health inequalities and finance leads

·         Public Health

·         South East Coast Ambulance Service (SECAmb)

4.30   The panel assessed against the appraisal criteria using recognised methodology and tested the weighting of the criteria fairly evenly. The outputs from the panel are included in the Decision Making Business Case at section 9, the full report from the independently facilitated site panel is contained in the report from Opinion Research Services (ORS) which is attached to the Decision Making Business Case at Appendix 7.

4.31   The summary outputs are as follows:

·         Overall, Eastbourne District General Hospital was identified as somewhat[3] better able to fulfil the criteria used to appraise the sites than Conquest Hospital, although it should be noted that both sites tended to be viewed nearly equally able to fulfil the criteria of Quality and Safety and Access and Choice.

·         This view was shared by the three ‘stakeholder groups’, and by the majority of participants, i.e., those with a connection to both acute hospital sites, or neither site.

·         The determining factors in reaching this outcome are that both sites tended to be broadly viewed nearly equally able to fulfil the criteria of Quality and Safety and Access and Choice by the majority of stakeholders, with a slight favour towards Conquest Hospital; but with the Eastbourne District General Hospital viewed by most stakeholders as being able to fulfil the Clinical Sustainability, Deliverability, and Financial Sustainability criteria somewhat better than the Conquest Hospital (and with a more significant margin).It is important to note, however, that there was evidence of strongly differing views among those who indicated a particular connection or affiliation to one site over the other, both in the appraisal scoring and in the way that the criteria were weighted; the group with a connection to Conquest Hospital only favoured that site against all criteria, and vice versa for those connected only to Eastbourne District General Hospital.

·         While this latter point was signalled as not necessarily impacting the decision-making process, consideration will be given to these differences in views during any post-decision consultation with stakeholders and at implementation stage.

 

Preferred site

4.32   We have carefully considered our equality and health inequality impact assessment and recognise the importance of supporting prevention and timely access to care and treatment through improved local services. This is addressed by this proposal which improves cardiology services for all service users and for 97% of cardiology service users, these improvements will be implemented locally at both the Conquest Hospital in Hastings, and Eastbourne District General Hospital.  This, alongside improved access (shorter waiting times for treatment) in the longer term is anticipated to have a positive impact in reducing the numbers of people who will require more specialist care as they are accessing improved care assessment, diagnosis and treatment earlier on in their clinical pathway.

4.33   For those patients who require a specialist service further along their clinical pathway, in making these improvements, it is necessary to consolidate our most specialist cardiology services onto a single site – Eastbourne District General Hospital - which also will result in significantly improved clinical sustainability of the service.  This change will mean that a small proportion of patients from Hastings and Rother area will travel further for these specialist services.  Of those who will travel further we have considered the recognised larger deprived population in Hastings as compared to Eastbourne, noting there is also significant deprivation within Eastbourne.

4.34   Part of our population based analysis considered the potential impact on people living in our most deprived wards in Eastbourne and Hastings. Based on the percentage of people in our most deprived wards, this indicates that there is a net differential impact of approximately 300[4] people who will be affected, who would have to travel further for their most specialist cardiology care. Approximately half of these will travel by ambulance or cross-site transfer. For those patients who would previously have accessed specialist care at the Conquest for a planned procedure and choose to travel by car there will be an average increase in travel of 15 minutes [5]. It should be noted that if the service were sited in Hastings, there would also be people from our deprived communities having to travel further. This further travel for some patients has been analysed and balanced with the clinical sustainability of the specialism that will ensure a viable service for the whole population.

4.35   We have taken account of feedback from our public consultation, HOSC Review Board recommendations and Travel and Transport Review Group recommendations to develop a package of measures to better support patients who may need support to travel to hospital as summarised in section 4.24.

Plans for implementation

4.36   This Decision-Making Business Case presents the public consultation feedback together with additional information and evidence that have been collated as part of this document’s development and in response to the consultation. The purpose of the Decision-Making Business Case was to enable and support the NHS Sussex Integrated Care Board’s decision-making process.The NHS Sussex Integrated Care Board met on the 2^nd of November and approved the recommendations in the Decision Making Business Case.

4.37   If the post-consultation proposal is formally supported by HOSC, we would enact our implementation plan from December 2022 for full implementation in January-March 2025, although early implementation of some elements of the model may be sooner than this, in order to realise quality benefits as quickly as possible.

Decision-making

4.38   The purpose of the Decision-Making Business Case is to ensure that the proposals have been consulted upon, are clinically sound, financially viable, and in line with the improved outcomes agreed in the Pre-Consultation Business Case. At their meeting in public on 11 October 2022, East Sussex Healthcare NHS Trust noted the development of the Decision-Making Business Case, including the feedback from the public consultation; and following their review of the summary Decision-Making Business Case, endorsed the case for consideration by the NHS Sussex Integrated Care Board. Following this NHS Sussex Integrated Care Board met on the 2nd of November and approved the recommendations in the Decision Making Business Case.

4.39   The decision was determined in two parts:

·         Firstly, confirmation that the case for change and pre-consultation proposals remained valid and have received support through the public consultation, and

·         Secondly, which of the two sites (Eastbourne District General Hospital or Conquest Hospital, Hastings) provides the best location for the very specialist reconfigured services. This was arrived at by reviewing all the evidence that has been used to inform this Decision-Making Business Case, including our pre-consultation engagement, public consultation feedback, our Equality and Health Inequalities Impact Assessment, Quality Impact Assessment, and the independently-facilitated site panel, and in light of this Eastbourne District General Hospital as the preferred site was approved by NHS Sussex.

5      Implications 

Financial implications:

5.1      There would be a positive financial impact on the Trust of implementing the changes outlined, this is as a result of implementing best practice and benefiting from resulting economies of scale.

Revenue

5.2      The case shows that under co-location there will be net efficiency savings, which takes into account the cost of capital, resulting in a favourable revenue position from year 3 for the recommended option. For comparison, the Conquest option results in a favourable position by year 4, once efficiencies can be realised.

5.3      The table shows the annual surplus / deficit position for both options when compared with the do nothing option. The preferred option (5a Eastbourne) is financially favourable, with an average 400k per annum additional efficiency savings above 5b Conquest, over the 10-year period.

5.4      The difference between the options is driven by lower capital investment due to less new infrastructure required, and earlier realisation of efficiencies for the preferred option due to the earlier implementation timescales.

Capital

5.5      The total capital required capital for the recommended option (5a Eastbourne) is £12.4m, with capital expenditure phased over three financial between 2023/24 and 2025/6. Full implementation of the model of care is planned from quarter 4 2024/25.

5.6      This compared to a total capital required capital for option 5b Conquest of £13.9m, with capital expenditure phased over three financial years between 2023/24 and 2025/6. Full implementation of the model of care is planned from quarter 4 2025/26.

5.7      The levels of capital outlined in this case for the recommended option can be funded within the Integrated Care System’s Capital allocation, in agreement with system partners.

Legal implications:

5.8      NHS Sussex has a legal requirement under the NHS Act 2006 to ensure patients and the public are involved in service changes. Therefore, the Gunning Principles as outlined above have been followed.

5.9      This underpins the pre-consultation engagement and the public consultation processes that have been followed for this programme.

5.10   Our Pre-Consultation and Decision-Making Business Cases have demonstrated compliance with former Clinical Commissioning Group and now Integrated Care Board statutory duties.

Other compliance

Data and Privacy Impact Assessment (DPIA)

5.11   The proposal has no impact or changes to what data would be processed nor how it would be processed. There would be no new or different organisations and/or providers involved in accessing and/or sharing patient information, and no new data processing systems would be utilised. No further Data Privacy Impact Assessment is, therefore, required.

NHSE/I Five Tests for service reconfiguration

5.12   Part of the evaluation of any service reconfiguration is the demonstration that five specific areas have been considered to determine the value of the project:

1.    that service users and the public are involved in the development of the proposals

2.    whether any proposed redevelopment would maintain the availability of service user choice

3.    demonstration of sufficient clinical evidence and clarity on the case for change

4.    assurance that the proposals have the approval of local commissioners

5.    relates to any proposal including plans to significantly reduce hospital bed numbers

5.13   Full consideration has been given to these points and details of which have been included in our Decision Making Business Case. In brief, the process has been clinically informed and led. Defining the vision for improved acute cardiology services across East Sussex involved a wide range of partners, these included service users, carers and their families, clinicians, including the service’s workforce, and other local communities and key stakeholder organisations such as Healthwatch. Feedback collated from the pre-consultation engagement was provided to inform decision-making and a wide range of stakeholders were involved in the options development and appraisal process to ensure different perspectives could be heard and accounted for in the decisions made. There will be no reduction in bed numbers.

Quality and Safety implications

5.14   The aim of transforming these services is to deliver significant clinical improvements that will improve quality, outcomes and safety for patients.

 

5.15   The Quality Impact Assessment has been completed in relation to the recommended option and in conjunction with the quality team. The Quality Impact Assessment is a live document and has been re-iterated throughout each phase of the programme and shown to have positive impacts.

Equality, diversity, and health inequalities

5.16   Integrated Care Boards have a duty to reduce inequalities between patients in respect to outcomes and access and this transformation has embedded health inequality considerations into the redesign process.

5.17   A Screening Equality and Health Inequalities Assessment was initially developed, followed by a full Equality and Health Inequalities Impact Assessment taking account of feedback from ICS colleagues and NHSE/I. This Equality and Health Inequalities Impact Assessment is a live document and has been re-iterated throughout each phase of the programme. Action from this has been undertaken, is reflected in the model of care, informed our public consultation and communications and engagement delivery plan, our site panel, and our communications plan post-decision. The Equality and Health Inequalities Impact Assessment is Appendix 1 of the Decision-Making Business Case.

Patient and public engagement

5.18   Following historical informal engagement, full pre-consultation engagement took place to understand what is important to local people. The information gathered during this engagement process informed our model of care and options appraisal process.

5.19   The transformation programme has been further informed by local people through our formal public consultation process, where the proposals were broadly welcomed with overall agreement on the proposed model of care, as there was recognition for the need to make changes to address challenges and deliver improvement to acute cardiology services.

5.20   In addition, our options development and appraisal process; our independently facilitated site panel included patients and patient representatives to inform our proposals as they have developed.

5.21   The feedback was helpful and a number of common themes were identified during the public consultation process, and initial actions in response to insight from the public consultation have included a review and update of the Quality Impact Assessment, Equality and Health Inequalities Impact Assessment, as well as updating of previous Equality and Health Inequalities Impact Assessment actions, and the establishment of a Travel and Transport Review Group, the actions of which have been, or are currently being, taken forward as part of the programme and when informing our final Decision-Making Business Case and recommendations.

Health and wellbeing implications

5.22   The transformation of services in East Sussex is expected to improve access to care and health outcomes for our patient population, supporting the health and wellbeing agenda and reducing inequalities.

6      Conclusion

6.1      The process to develop these proposals has been comprehensive and the recommended model will deliver benefits for our local populations. We are proposing to improve services for the vast majority of patients who access cardiology services at both hospital sites, alongside consolidating our very specialist services onto a single site to improve clinical sustainability of these and the overall service, ensure future quality of clinical care and enable the introduction of Cardiac Response Teams and hot clinics at both sites. 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.

6.2      Through our engagement and options development and appraisal process we developed five potential model of care options. During the Pre-Consultation Business Case, and public consultation, with patients, the public and local stakeholders, the conclusion was to recommend the post-consultation proposal detailed in the Decision-Making Business Case. This is the same model of care that was appraised (as part of our options development and appraisal and pre-consultation processes) as the one that will best provide good patient experience, support improved outcomes for local people and a high-quality sustainable service, enabling the model of care to be implemented that will realise these benefits and is deliverable.

6.3      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 implementation and evaluation processes to continue to understand the implications of our proposal. All new information and evidence gathered as part of an evaluation will inform how the final proposal is working.

6.4      Subject to the outcome of the East Sussex Health and Overview Scrutiny Committee’s consideration as to whether the proposals are in the best interests of local people, mobilisation will begin.  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 understand how best to provide easily accessible information to support local people and professionals about the changes, and to communicate the 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.

 

 

 

 

 

 

 

 

 

 

 

Annex 1: Themed actions in response to public consultation and recommendations

Following the feedback from the public consultation, the HOSC Review Board and the Travel and Transport Review Group made a range of recommendations which have been taken account of as we have developed our proposals and our developing draft mobilisation planning. These key recommendations were focused on travel and transport and included providing travel support for local people; the introduction of Travel Liaison Officer at East Sussex Healthcare NHS Trust; improved communication about travel options; liaising with patients about their individual travel and access needs; supporting patients with information and processes about accessing financial reimbursement where eligible; improving information for patients about alternative transport options and exploring over the longer-term improvements to public transport; and measures to support recruitment and retention of staff.

In response to these recommendations, some have been implemented and others have been committed to and we are progressing them as this programme continues and we implement our proposals. There are also several actions/recommendations which are being pursued and/or explored by the wider Sussex system, as these do not solely relate to cardiology patients who attend East Sussex Healthcare NHS Trust. Themes, recommendations and progress updates are detailed in the table below.