Ophthalmology Transformation at East Sussex Healthcare NHS Trust

 

HOSC Update – March 2025

 

1      INTRODUCTION

Background and Context

1.1      In the Autumn of 2022, following a full public consultation process, a Decision-Making Business Case (DMBC) was finalised by East Sussex Healthcare Trust (ESHT) in partnership with NHS Sussex Integrated Care Board (ICB) with the primary goal of enhancing patient outcomes through the implementation of the proposed ophthalmology transformation.

1.2      Specifically, the ophthalmology transformation proposal was to locate ophthalmology services at two hospital sites, Eastbourne District General Hospital and Bexhill Hospital, supported by one-stop clinics at both hospitals, and a diagnostic eye hub at Bexhill Hospital.

1.3      The ESHT Trust Board approved the DMBC on the 11^{th of} October 2022, which was followed by the approval of the ICB at their public board meeting on the 2nd of November 2022.

1.4      Following NHS internal approval. The DMBC was submitted to the East Sussex Health Overview and Scrutiny Committee (HOSC), who endorsed the DMBC at their public meeting on the 15th of December 2022.

1.5      A full list of activities completed as part of the options development and appraisal process, and the full public consultation process, can be found as Appendix A to this paper.

Ophthalmology Transformation Proposal Summary

1.6      In summary, the proposal approved by NHS Sussex, and endorsed by the HOSC, was to improve the services at both hospital sites through the formation of one-stop clinics, and at Bexhill Hospital, and the implementation of a diagnostic eye hub; both of which would enable rapid assessment for patients, reduce waiting times, and decrease the number of individual appointments needed.

1.7      The proposed transformation, with the one-stop clinics and diagnostic eye hub, will make key quality improvements to the service, such as:

·         enable redesigned ophthalmology pathways that will increase quality of care ensuring patients are seen by the right person, in the right place, and at the right time.

·         ensure that we can better meet service standards so that patients receive care in a timely manner, meaning faster diagnosis, shorter waiting times, fewer repeat appointments for tests and therefore less travelling for patients.

·         provide a consultant-led model of working that efficiently utilises skill mix across the workforce and provides training opportunities.

·         ensure staff and expert knowledge are consolidated, allowing for improved supervision and opportunities for training and educational needs for staff who wish to upskill. Thereby, gradually improving the skills in the workforce to improve the service quality and care provided to our population.

1.8      This proposal will have positive impacts for our patients, as well as workforce, and will improve patient experience, patient outcomes and our performance against national standards in the long term by reducing waiting times alongside repeated travel for patients, whilst making the service more efficient and sustainable for the future.

1.9      The proposal also supports the wider Sussex Ophthalmology plan enabling future training and supervision from ophthalmology consultants to upskill the community Optometry workforce.

Governance and Reporting Arrangements Following Approval

1.10   Following approval of the proposal made in the DMBC, arrangements were made for the ophthalmology transformation programme to report monthly into the ESHT Transformation Board, which provides oversight and steer for the programme, including the monitoring of risk and issues on an ongoing basis.

1.11   In turn, the ESHT Transformation Board reports into the ICB Joint Steering Board (JSB), which retains system oversight of the ophthalmology transformation programme from an ICB perspective and includes representatives from a wide range of stakeholders (including public stakeholders), who have largely continued their roles from the consultation phase.

Purpose of this paper

1.12   This aim of this paper is to provide an update to the HOSC regarding the key actions against their recommendations made on the 15^th of December 2022, and well as to provide additional context on the implementation plans and activities which have been undertaken since the last update in December 2022.

1.13   Please note, the recommendations made by the HOSC on the 15^th of December 2022 followed on from a larger set of recommendations made by both the ‘HOSC review Board’, and the ‘Travel and Transport Review Group’. These recommendations were discussed at the HOSC meeting on the 15^th of December where a number of updates were given, and some actions had already been implemented, investigated and closed.  The resulting list of HOSC recommendations were therefore distilled from this larger list, and these are the ones that are addressed directly in this paper.

1.14   However, the programme team have continued to review this larger list periodically, as part of the ‘Mobilisation Assurance Actions’ process overseen at the Joint Steering Board. An update to the actions on the wider list can be found as Appendix B to this paper.

 

 

2      HOSC RECOMMENDATIONS

 

2.1      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 and implemented our proposals.

2.2      All actions have remained under review during implementation phase and have been discussed on a quarterly basis at the ICB Joint Steering Board, as part of a standing agenda item on ‘Mobilisation Assurance Actions’.

2.3      The HOSC meeting on the 15^th of December 2022 reviewed this longlist of recommendations and considered each one in turn. Some of those actions had already been completed and closed, and some remained open. (The full list of these recommendations, as well as actions taken in response to them, is given in Appendix B of this paper).

2.4      Those actions that remained open, and were supported by the HOSC, were distilled into a series of 6 recommendation made by the HOSC when endorsing our proposals on the 15^th of December 2022. An update to each of these recommendations is provided below.

Recommendation 1

The Committee endorses the reasons for reconfiguring ophthalmology including:

·         Clinical case for change and the potential for new services to improve patient care and experience.

·         The creation of the ‘Centre of Excellence’ diagnostic hub, one stop clinics, and measures to support staff recruitment and retention.

2.5      Phases 1 and 2 of the Ophthalmology transformation programme have now been completed, which has expanded the ophthalmology footprint at Bexhill Hospital, and allowed the consolidation of medical staff onto the Bexhill Hospital site.

2.6      This has allowed us to deliver the model of care described during the consultation, including the provision of a Bexhill diagnostic hub, as well as the development of one-stop clinics where these are currently possible. Some pathways work is still underway, which will allow us to further expand our offering of one-stop clinics in the future.

2.7      There have been some unforeseen delays in implementation, however, we have now started to realise the benefits outlined in the original DMBC (See Section 4: Benefits from phase 1 and 2, below).

 

2.8      We are currently completing an initial benefits realisation project, which will help us to understand the scale of the improvements already made, and where we should focus our efforts next.

2.9      The impact of the new model of care has also meant that we have been able to successfully recruit to long term vacant posts, which helps reduce reliance on bank and agency, and ensure the future sustainability of the service.

2.10   Phase 3 (related to the consolidation of Optometrists and Orthoptists) is currently under review in order to make the best decision around the use of resources for our patients given capital constraints and unforeseen operational changes.  More details on phase 3 plans are given as part of the implementation update in Section 3.13 of this paper.

Recommendation 2

The Committee notes that the proposed choice of the Bexhill Hospital to consolidate ophthalmology services and recommends that mitigation measures are put in place to address the concerns about travel and access to this site.

2.11   General travel and access recommendations that were provided as part of the consultation feedback, the ‘HOSC Review Board’, and the ‘Travel and Transport Review Group’ have been addressed or investigated, and continue to be reviewed as part of the mobilisation assurance actions at the ICB Joint Steering Board (See Appendix B).

2.12   The Trust regularly reviews patient feedback and satisfaction and will continue to do so. Feedback on the transformation programme has been positive and has reflected an increased satisfaction following the implementation of the new model of care. Patient DNA rates have dropped, and were always lower at Bexhill than Conquest, which has provided confidence that patients are, in the main, not experiencing travel and access difficulties in attending their appointments.

2.13   Specific travel and access recommendations are given as part of ‘recommendation 3’ below, and updates to these are provided in the next section.

Recommendation 3

The Board recommends:

3a. A package of measures is put in place to mitigate the travel and access impacts of the proposals on patients, families, and carers, including but not limited to:

·         the establishment of a Travel Liaison Officer post is essential.

2.14   The travel liaison officer role was intended to provide a single point of contact for patients who are experiencing difficulty in attending their appointment or arranging hospital transport.

2.15   The ‘Travel liaison Officer’ role has since been fulfilled by the single point of contact that is provided as part of the new Sussex wide NEPTS contract which came into effect last year. This role provides a single place where patients can call to discuss their travel arrangements and difficulties and has the benefit of being open to all hospital patients, not just those accessing ophthalmology services.

2.16   The ophthalmology service at ESHT benefits from a new Eye Clinic Liaison Officer (ECLO) role, a role endorsed by the UK Ophthalmology Alliance. The ECLOs provide patients with a point of contact within the service and can be contacted for practical and emotional support to patients, including advice and help around attending appointments.

·         the communication and clear messaging of advice and guidance on travel support options, including accessing financial support, including the ability to claim back travel costs following appointments etc.

2.17   Since the consultation we have updated the advice on our Trust communications to include clearer advice on travel support and financial support for travel costs where patients are eligible. This information is now included on relevant patient letters, as well as being available on our website.

2.18   The information given has been standardised to avoid confusion, and the same information is given by the Trust as by other sources, such as by the new NEPTS service.

2.19   Where patients are eligible, patients can also receive reimbursements for travel costs whilst attending their appointment by visiting the cashier’s office on site. Patients are informed of eligibility criteria and told in advance what documents they will need in order to claim back their travel expenses.

·         the provision of information on the travel support available in referral letters via a separate leaflet or information sheet in an accessible format and links to the website.

2.20   As above, this information is now included on patient letters and on our website, and accessible formats are available. This follows a Trustwide programme to standardise and review the information on clinic letters across the Trust, and align this with information from other sources, such as online.

·         the CCG (now ICB) and ESHT explore processes to ensure patients are asked about their travel and access needs at the point of referral or at an appropriate point in the patient pathway.

2.21   As part of communication to patients from the Trust, it is highlighted that patients can get in touch to raise any difficulties they may have in attending their appointment, and appropriate contact details are given for them to do so.

2.22   If it is a patient’s first appointment, the Trust will rely on either 1) the patient getting in touch to let us know if they have particular difficulties, or 2) the information being available at the point of referral, in order for the Trust to be able to take action to assist. It is not possible or viable for the Trust to check personally with every new patient ahead of their first appointment.

2.23   However, as part of raising awareness of this issue with referrers directly, the ICB have asked referrers via identified groups (Such as at GP meetings) to include any travel and access requirements on their referrals when referring patients into the Trust. The roll out of this message was monitored at the ICB Joint Steering Board, and the message will be repeated periodically.

·         encourage providers to provide clear explanations of the eligibility criteria for Patient Transport Services.

2.24   As explained above, eligibility criteria for patient transport services have been recently refreshed and clarified as part of the new NEPTS contract. This information is available online or by phone and is aligned with the information given by the Trust. Patients can also access the single point of contact if there is any confusion.

·         increasing and maximising the number of on-site parking spaces at the Bexhill Hospital site.

2.25   Works to increase the car parking capacity at Bexhill will be completed in March 2025. This will include an additional 13 parking spaces, which is in excess of the number of spaces which required as part of the ophthalmology plans.

2.26   Furthermore, there are further plans being developed for a potential phase 2 of the car parking expansion, which, if successful, will provide an additional 8 spaces above the 13 already planned. The plan for the phase 2 expansion are currently being developed.

·         actions to improve access via other transport alternatives (e.g. development of a shuttle bus service, volunteer transport services, community transport, taxi services, liaison with bus operators and the local authority etc.).

2.27   The travel and transport group investigated the feasibility of a shuttle bus, however, the conclusion was that a shuttle bus would likely not be a viable option, or serve the patients we would aim to reach, as patients do not generally travel between hospital sites for these appointments, but instead travel from their home addresses.

 

2.28   However, a financial viability assessment was conducted by the Trust to determine the options available for providing a shuttle bus. In every scenario the numbers of travellers required in order to make the shuttle bus service a viable and justifiable use of public funds were felt to be unachievable.

2.29   Notwithstanding the above, patients who are having difficulties in reaching their appointment for clinical or financial reasons are able to access NEPTS if they fall within the eligibility criteria, or can contact an ECLO in the ophthalmology service.

2.30   A library of volunteer transport services was collated as part of this action by the programme team. This was then written into the NEPTS contract refresh in order to be maintained as part of the single point of access requirements. This library is now maintained and updated by the NEPTS provider.

2.31   The Trust and the ICB met with Transport managers at ESCC to discuss the transformation plans and potential improvements to transport links. Despite investigating the opportunities, the local bus improvement plan funding was not available to be used for this due to targeted plans for where the funding was needed most. However, the transport manager is cognisant of our plans, and a relationship is maintained such that the Transport manager will report back on any potential future opportunities.

2.32   Furthermore, the Transport Manager investigated the possibility of amending or altering bus routes operated by Stagecoach to better serve Bexhill Hospital. Stagecoach concluded that a change in route was not viable due to 1) the logistics of the vehicles and the limitations of road size, and 2) that additional routes and alterations were not financially viable for the operator. Additionally, it was reported that buses along the proposed route were historically underutilised, and the limited demand for this service led to its previous withdrawal.

3b. Ongoing monitoring of Did Not Attend information is undertaken after implementation of the proposals to establish the reasons why patients do not attend appointments, and review the travel and access mitigations in the light of this information.

2.33   DNA monitoring is conducted by the Trust and the service on a rolling basis, and actions are continuously taken to improve a DNA rate where this is required.

2.34   DNA rates for Ophthalmology have improved at Bexhill, in comparison to the baseline for the DNA rates at Conquest, giving us confidence that patients are experiencing less difficulty in access their appointments that under the previous model.

2.35   Furthermore, complaints for ophthalmology relating to travel and access remain low. Feedback received from patients on the new service has been largely positive.

2.36   Further details on DNA rates and patient satisfaction will be contained within the benefits realisation which is currently being conducted.

 

Recommendation 4

The Board recommends:

·         Patients are given a choice of hospital site for referral where appropriate.

·         Consideration is given to providing some specialist treatments at the Eastbourne DGH site in addition to Bexhill Hospital.

2.37   Patients continue to have a choice over the hospital they attend where this is possible and where it is safe to offer. Outpatient clinics are provided by ESHT at both EDGH and Bexhill, and both EDGH and Bexhill are equipped with eye theatres to support the service.

2.38   There are a limited number of subspecialty procedures which can only be provided at one or other site owing to the specialist staffing or equipment required which is not duplicated across sites. Where this is the case, this is because of limitations in demand which makes duplication of service inefficient. This has always been the case and is not an impact of the transformation plans.

2.39   We actively monitor demand for these services, and if this changes in the future, then alternative options will be considered.

Recommendation 5

The Board recommends:

·         Detailed implementation plans are drawn up as soon as possible to facilitate the timely implementation of the proposals, once a decision is made.

·         The opportunity is taken to make early changes to services where this is possible.

2.40   Detailed implementation plans started to be drawn up immediately following approval and endorsement of the DMBC. A detailed update to these implementation plans can be found in section 3 below.

2.41   As part of the ongoing governance and programme management, we are always looking to ensure that any benefits can be realised as early as possible. Re-review of demand and capacity across phases 1, 2 and 3 of the programme meant that we were able to take the best decision to maximise benefits by consolidating the medical workforce first, following the implementation of phases 1 and 2 (see section 3 below).

Recommendation 6

The Board recommends:

·         Regular monitoring of staffing levels is undertaken post implementation to ensure the sustainability of the service.

·         Further staff recruitment and retention measures are developed.

2.42   Staffing levels, recruitment and retention are monitored on an ongoing basis. Measures are developed in response to the monitoring of these metrics, and actions taken where required. The service continue to measure workforce metrics on a rolling basis.

2.43   We have recently been able to recruit to longstanding vacant consultant posts due to the transformations plans that we have implemented. This has reduced reliance on bank and agency and helps to safeguard the future of the service. It also aids in training and development for both medical and other groups of staff.

 

3      IMPLEMENTATION UPDATE

Original DMBC Implementation Timescales

3.1      An indicative implementation plan was developed as part of the DMBC process, which illustrated the ambition of the ophthalmology transformation plans, and provided a high-level road map for mobilisation.

3.2      The indicative implementation timescales that were given in the DMBC are reproduced below for reference, along with the notes and assumptions included at that time.

* Notes/Assumptions

1. No further business case approval process required following agreement of Decision-Making Business Case and East Sussex Healthcare NHS Trust internal approvals.

2. External funding sources / capital budget have been and are agreed by the system for all works.

3. Regarding reprovision of X Ray service space, this assumes the planned Community Diagnostic Centre in Bexhill opening as per plan in autumn 2022, and not later than December 2022.

4. Location of Physiotherapy to be confirmed. Assumes Physiotherapy move and works to accommodate new Physiotherapy can be completed to fit with Ophthalmology timescales.

3.3      There have been some delays to the programme following development of more detailed plans. These delays are largely due to 1) a deeper understanding of the scope of the work required at each stage, 2) emergent work which has been uncovered (such as upgrading of digital infrastructure), and 3) difficulty with interdependencies (such as the assumptions made around MSK relocation). There have also been some small-scale delays in general procurement and construction processes. Further details of the delays at each stage of the works are given below with the details of the phasing.

3.4      All delays have been raised via the risk and issues process to the ESHT Transformation Board, and the ICB Joint Steering Board. In all cases these committees have received assurance that all mitigating actions have been taken where possible, and all efforts have been made to minimise the impact on the timescales for realising the benefits of the model of care for our patients.

3.5      Notwithstanding the delay in implementation outlined above, the programme has progressed to the stage where it has completed 2 out of the 3 phases of estates work.

3.6      This has meant that we have been able to consolidate the medical workforce onto the Bexhill Hospital site, allowing us to implement the most impactful elements of our model of care. As a result, we have started to realise some of the benefits outlined in the DMBC.

3.7      Furthermore, phase 3 has been put on hold pending a re-review of the options for this part of the transformation. Estates options are currently being developed (within the parameters of the original proposal), and an update can be provided once options have been sufficiently developed and considered. Further details are provided under ‘phase 3’ below (Section 3.13).

Implementation Phasing

3.8      Following approval to proceed to implementation, more detailed plans were drawn up, which included an operational and workforce plan, and an estates and facilities plan.

3.9      Implementation was planned in three phases in order to enable the estates improvements, whilst continuing to provide clinical services as required from the Bexhill hospital site. The three phases were:

3.10   Phase 1: Refurbishment of Bexhill X-ray Unit (September 2023 – February 2024)

Phase 1 work has been completed and consisted of:

·         X-ray provision ay Bexhill Hospital was relocated to the new Community Diagnostic Centre (CDC) which was opened in the Bexhill area.

·         A critical digital infrastructure upgrade was installed at the Bexhill Hospital site.

·         Work was completed on structural and roofing elements of the Bexhill Hospital site, in the areas that were planned for Ophthalmology.   

·         The old X-ray area at Bexhill Hospital was then refurbished for use by ophthalmology, creating additional clinical rooms and capacity.

·         Ophthalmology service provision continued as normal throughout this period at Conquest Hospital and Bexhill Hospital, while phase 1 work was completed.

There were some delays to beginning phase one of the works, as well as an extension to the required timeframes to complete the necessary estates work. This was largely due to three factors:

·         There were some small delays in moving the X-ray activity to Bexhill due to delays in the national CDC process which was being rolled out at a similar time.

·         Prior to phase 1 estates work starting, it was necessary to upgrade the digital infrastructure at Bexhill, the urgency of this work was unforeseen and had not been planned in, but was needed to be completed before the ophthalmology refurbishment could start. This work included trenching, which was required around much of the Bexhill site.

·         Phase 1 work also coincided with essential structural and roofing works that were emergent and only fully recognised at the time the phase 1 build was started.

Work between the radiology unit and the structural and roofing elements needed to be coordinated and phased in order to plan around sustaining clinical activity during opening hours, in order to minimise potential impact on patients.

Mitigations were put in place in order to ensure that there was minimal impact on transformation plans and to patients. This included progressing other elements of the plans where possible, such as:

·         Designing and testing the new operational pathways where this was feasible.

·         Completing a demand and capacity exercise for phases 1 and 2 in order to allocate rooms to staff and activity type.

·         Ensuing preparations for the Staff Consultation with HR were ready to launch at the right time to ensure staff could move from Conquest when phases 1 and 2 were complete.

Planning for phase 3 was separated out at this point, as it became apparent that the assumptions for phase 3 space had materially changed. This will be covered below in the section on phase 3.

3.11   Phase 2: Dowling Unit Refurbishment (March 2024 – October 2024)

Phase 2 work consisted of:

·         Decant of the then current ophthalmology service and equipment from the old Dowling Unit space into the new ophthalmology space created in phase 1 (Staff who were already based at Bexhill Hospital moved into the newly refurbished space).

·         Refurbishment and redesign of the old Dowling Unit space, to allow for additional capacity, and to address access issues in the old unit.

·         Ophthalmology service provision continued as normal across the Conquest and Bexhill Hospital sites while phase 2 work was completed.

·         Limited piloting of new pathways was tested during phase 2, following pathways work conducted throughout phases 1 and 2.

Estates work for Phase 2 was completed with minimal delays but was affected by the later than planned start for phase 1, which affected the timescales for the phase 2 procurement and contracting process. The minimal delays that did occur during phase 2 were largely due to supply and demand issues with materials from the contractor’s, responding to market volatility at the time the work was caried out.

Ophthalmology staff took ownership of the new space in the weeks following completion of phase 2 building works (between October and November 2024).

Communications were planned around the phasing to help publicise the changes to the public. Further communications are planned as part of our ongoing Communications and Engagement plan.

3.12   Staff Consultation and Workforce Planning

Following the completion of phase 2, it was possible to move some Ophthalmology staff over from Conquest Hospital to Bexhill Hospital, which required a Staff Consultation with the HR department.

The HR Consultation had been prepared during phase 1, and was completed simultaneously with estates works for phases 1 and 2. This allowed for staff to move into the phase 1 and phase 2 units at Bexhill from Conquest as soon as the building works were completed, and the rooms were ready to be used.

Feedback from the staff during the consultation was largely positive, and staff were on board with the changes; this was especially the case as the model of care had been clinically led throughout the public consultation phase. Only a light touch Staff Consultation was required due to positive feedback from the staff, and the large the amount of engagement with the workforce which had been completed to date.

Workforce planning was completed following the demand and capacity exercise conducted during phase 1, and this allowed the medical workforce to move from Conquest to Bexhill when the new unit opened.

Please note, the Optometry and Orthoptist workforce currently remains at Conquest, awaiting review and development of plans for phase 3 (see below).

3.13   Phase 3: Refurbishment of MSK (Physiotherapy) Unit

Work on phase 3 has been temporarily paused and is currently under review. This is due to several factors, the main ones of which are indicated below:

·         Initial planning for phase 3 recognised in the assumptions of the DMBC that the MSK service currently provided in that space had to be relocated. A location had to be found within close proximity to the current site as to minimise impact to patients.

·         An alternative MSK location was identified by way of a rental solution, and initial preparations were made to lease a space for the MSK team. However, during the planning phase it became apparent that the costs required to bring this space up to the standards required for clinical activity were more than anticipated, and were in excess of capital estimates.

·         There was not the capital funding available at the time in order to complete the required works, which prompted a re-review of the phase 3 plans. This also coincided with a capital reprioritisation programme which was being conducted due to an oversubscribed capital plan, and constrained capital across the system was being reviewed and re-prioritised.

·         This resulted in a review of the immediate need for the additional space which would have been provided by phase 3. The review found that:

o   Phases 1 and 2 could be used to relocate the medical workforce in its entirely (as outlined above), and this would allow us to achieve the majority of the benefits outlined in the business case – this has now been completed.

o   The phase 3 space concerned the consolidation of the Orthoptist and Optometrists. However, these staffing groups can continue to safely and effectively work at the Conquest site, as this work does not require consultant supervision.

o   The activity and growth included in the business case was a 10-year model. Updated demand and capacity revealed that the additional phase 3 space at Bexhill was not imminently needed.

o   This has allowed us time to re-evaluate what phase 3 looks like and investigate alternative and viable options from a capital perspective, before committing public money to phase 3. This work is currently underway.

o   It was acknowledged that phase 3 would still be needed in the future, in order to provide the training and development required to enable the non-medical workforce (Optometrists and Orthoptists) to see activity that would traditionally be seen by medical staff, and to ensure that we can meet the modelled growth in the 10-year forecast period.

o   Additionally, this re-review came at a time where independent sector providers were increasing their footprint in East Sussex, possibly affecting the assumptions behind the future growth model included in the DMBC.

o   As result, it was felt that the impact of a growing independent sector presence should be understood and modelled before making a firm decision on the future of phase 3, as it may lessen the hospital footprint required.

o   This work is ongoing and will feed into an options appraisal for phase 3.

Updates on the above ongoing work are report and monitored on a monthly basis at the ESHT Transformation Board, who will review the development of phase 3 proposals.

All delays and developments are reviewed by the ICB Joint Steering Board, who oversee decision making, risk, and issues. Delays have been escalated to the ICB JSB in each case, and assurance has been sought in each case that delays have been mitigated as far as possible.

The JSB are also received reports monitoring the impact of the increased footprint in independent sector ophthalmology providers across Sussex.

3.14   Car Parking Expansion

Alongside the three phases which directly related to the provision of the ophthalmology service, separate but related plans were developed to enable the expansion of the car park at Bexhill.

Groundwork is currently being conducted to expand the car park at Bexhill, and ahead of any phase 3 plans which will bring further activity to the site.

The design and planning process for the new car park allowed for us to maximise the number of spaces, achieving an additional 13 spaces, which are in excess of the number of spaces that were required during consultation in order to subsume the additional ophthalmology activity which would be brought to the site due to the transformation.

The work on the expansion of the care park is due to be completed in March 2025.

Furthermore, the Trust is in early discussions around the possibility of a phase 2 car park expansion, which may provide a further 8 spaces if plans are successfully approved.

 

4      BENEFITS FROM Phase 1 & 2

Improvements and Benefits in Place

4.1      The medical workforce has been consolidated from Conquest to the Bexhill site.

4.2      New medical rotas are in place which has eliminated the need for consultants and middle grades to travel between sites within the working day.

4.3      New job planning for consultants and medical workforce have been partially completed (with the remaining job plans to be completed this year), and are line with Royal College of Ophthalmologists guidance.

4.4      There has been an increase in direct clinical contact (DCC) time, which in turn increases the amount of activity that can be seen by each individual, and the service as a whole. Service provision has been planned on a room capacity and sub-specialty basis.

4.5      New pathways are now in place for medical sub-specialties, which has allowed the provision of one stop clinics for approximately 40% of patient pathways appropriate for one stop, and this number is increasing.

4.6      A reduction in DNAs from patients, and an improvement in patient satisfaction and friends and family tests.

4.7      Increased supervision and improved training for medical staff, as well as for non-medical staff – however, optimising training and development for some non-medical staff groups will need to wait until phase 3.

4.8      Improvement in recruitment and retention of staff. We have managed to recruit to longstanding vacancies, which includes the appointment of a number of substantive consultants. This in turn reduces our reliance on bank and agency staff, which reduces the cost of activity, and improves the continuity of care for our patients.

4.9      A consultant-led rather than consultant delivered service has been implemented, which is supporting junior doctors and trainees, and improving decision making and outcomes for patients. Improvements include:

·         an increase of patients on PIFU (Patient initiated follow up) pathways.

·         a reduction in the frequency that patients are having to attend for follow up outpatient appointments (this will not show in the data until approximate 6-12 months after due to the way follow ups are booked)

·         an increase in the capacity for the medical workforce to see new patients, improving the new to follow up (N:Fup) ratio.

Benefits Realisation Plan

4.10   Due to the delays inherent in implementation, the full benefits realisation that was originally planned for Summer 2024 has not yet been finalised.

4.11   Benefits realisation is being conducted on phase 1 and 2 benefits currently and can be brought back to the HOSC once completed.

 

Appendix A - The consultation Process

Our Case for Change and developing our Pre-Consultation Business Case (PCBC)

Following analysis of the current service provision and the emerging future needs of local people, we developed a Case for Change that outlined the key drivers for service transformation. This provided the basis for our engagement with local people, clinicians and other professionals to further understand what is important to them about ophthalmology services. This initial engagement indicated several key themes as important to local people:

·         Care provided

·         Equality and diversity

·         Access and transport

·         Clinical services

·         Community optometry.

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 development of our proposals.

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

Following this, and as part of our in-depth comparative analyses, 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.

A Pre-Consultation Business Case (PCBC) was developed to make the case for change and set out the plans for a Public Consultation around the transformation of ophthalmology services at East Sussex Healthcare NHS Trust. The PCBC 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 (HOSC) on 2 December 2021 prior to formal public consultation. An independent report on the findings of the consultation was produced and presents the feedback from those who participated in the consultation (this report can be found in the Appendix 3 of the final published Decision-Making Business Case).

When developing our options, our draft proposals, the Pre-Consultation Business Case and Decision-Making Business Case:

·         We considered the outputs from engagement and consultation with local people and clinicians and used these to inform the Pre-Consultation Business Case and Decision-Making Business Case.

·         We developed the Pre-Consultation and Decision-Making Business Cases 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 assessed the impacts of our proposals by undertaking a Quality Impact Assessment and an Equality and Health Inequalities Impact Assessment to identify any potential negative impacts and identified appropriate mitigating actions.

·         We commissioned an independent travel analysis to understand the impact of the proposals in this regard.

·         We took into account the recommendations of the South East Clinical Senate.

·         We considered opinions and insight from a number of service leads and managers within our acute hospitals in East Sussex that represent a broad range of clinical specialties.

·         We were informed by feedback from the East Sussex Health Overview and Scrutiny Committee including the East Sussex Health Overview and Scrutiny Committee Review Board.

·         We assessed our proposals against the NHS Four Tests for service reconfigurations.

·         We undertook stage one and stage two process with NHSE to assure our plans prior to public consultation.

·         We developed our proposals, and associated consultation plans in line with the Gunning Principlesto ensure that:

o   a decision would not be taken until after public consultation.

o   local people and stakeholders had information that enabled them to engage in the consultation and inform our decision.

o   there was adequate time for people to participate in the consultation.

o   we could demonstrate how we have taken account of engagement and formal consultation by publication of a consultation feedback report describing this.

 

Public Consultation

The formal public consultation into the proposal to transform ophthalmology 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 the site options.

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 is Appendix 3 of the Decision-Making Business Case.

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 (EHIA).

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

Alongside public consultation, East Sussex Health Overview and Scrutiny Committee 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 Review Board carried out its review between April and June 2022. A full report was included in the Decision-Making Business Case, and set out the evidence the Board considered, along with its conclusions and recommendations.

On balance, the Health Overview and Scrutiny Committee Review Board considered that the proposed changes to the ophthalmology services in East Sussex are in the best interests of patients and asked that adequate mitigations to be put in place to address the travel and access issues that were identified.

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 Review Board were presented to the HOSC and fed into the summary recommendations made by the HOSC when it considered evidence for the proposals on the 15^{th of} December 2022. These recommendations are addressed in section 5.

Travel and Transport Review Group

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.

The group was tasked with reviewing findings from the pre-consultation engagement processes, options development and appraisal processes, Equality and Health Inequalities Impact Assessment (EHIA), 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.

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. 

Following the review outlined above including insight from the public consultation, the Travel and Transport Review Group made several recommendations which were included in the DMBC.

As with the recommendations of the HOSC Review Board, the recommendations from the Travel and Transport Review Group also fed into the summary recommendations made by the HOSC when it considered evidence for the proposals on the 15^{th of} December 2022. These recommendations are addressed in section 5.

Plans for implementation

The Decision-Making Business Case presented the public consultation feedback together with additional information and evidence that have been collated as part of the 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.

Once the post-consultation proposal was formally supported by the East Sussex Health Overview and Scrutiny Committee, we began to enact our implementation plan from December 2022. Early implementation of those elements of the model which could be put in place early were kept under review via the programme governance in order to realise quality benefits as quickly as possible.

Approval, endorsement and implementation

The purpose of the Decision-Making Business Case was to ensure that the proposals were adequately consulted upon, were 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.

NHS Sussex Integrated Care Board then met on the 2^nd of November and approved the recommendations in the Decision-Making Business Case.

Following this, the DMBC was submitted to the East Sussex Health Overview and Scrutiny Committee (HOSC), who endorsed the DMBC at their public meeting on the 15th of December 2022, and the programme moved to implantation phase.

Appendix B – OTHER consultation RECOMMENDATIONS

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 moved into implementation phase.

These key recommendations were largely focused on travel and transport issues that had been highlighted during consultation and included investigating provision of numerous travel and access support options for local people.

In response to these recommendations, an update was provided at the HOSC meeting on the 15^th of December 2022, where it was recognised that some actions had already been implemented, others had been committed to and were progressing as we moved to implementation, and others had been investigated but were not viable options. As such, the recommendations were distilled to the 6 HOSC recommendations which are the subject of section 2 of the above report.

 

All actions have been under constant review during the implementation phase and have been discussed at the ICB Joint Steering Board on a quarterly basis as part of the ‘Mobilisation Assurance Action Log’.

 

Themes, recommendations and progress updates are given in the table below in order to provide additional detail and context for the HOSC members.