Consultation on A Picture of Health for outer south east London Introduction Bromley, Greenwich and Lewisham Primary Care Trusts (PCTs) and Bexley Care Trust have been working together to plan safer and better quality healthcare services for the four London boroughs of outer south east London. West Kent PCT has also been involved with this work as residents of north west Kent use some of the services provided in outer south east London. Formal consultation on proposals for change is scheduled to start on 7 January 2008 and end on 7 April 2008. The proposals focus on both the fundamental improvements to the way hospital services are organised in outer south east London and the development of out of hospital. The four district general hospitals in outer south east London are: • Princess Royal University Hospital, which is part of Bromley Hospitals NHS Trust; • Queen Elizabeth Hospital; • Queen Mary’s Sidcup; and • University Hospital Lewisham. The clinical strategy - A Picture of Health (APOH) - has been drawn up under the guidance of the APOH Project Board and Executive (both chaired by Simon Robbins, Chief Executive of Bromley PCT). This paper asks the Board to note the options for change on which consultation is proposed and asks the Board to satisfy itself that the pre- consultation business case underpinning the proposals is sound. It also asks the Board to note the PCTs’ plans for consultation. When proposals for service reconfiguration involve several organisations, the Board’s role in respect of this is to note and agree the process approved by the PCTs, including the Consultation Document. However, NHS London has no statutory obligation in respect of local service reconfigurations. But in line with best practice, the executive of NHS London has been working closely with the APOH project team to ensure the PCTs’ pre-consultation business case is sound and that the Consultation Document is fit for purpose. The draft (to be designed) Consultation Document and the latest version of the pre-consultation business case are attached. A full programme of consultation events has been planned to accompany the consultation period. The approach for this is included in the Consultation and Engagement Plan – this is provided to the Board for information. The case for change in outer south east London Care and treatment in hospital is not always the answer - most people are best cared for by community services in line with the Our health, our care, our say White Paper. When a patient does need the full resources of a modern hospital it is for specialised care. Therefore, the underlying principle of planning service delivery in the future will be the right care in the right place at the right time, as close to home as possible, consistent with safety and quality. The case for change for APOH is focused squarely on the urgent clinical and financial issues faced by the NHS in outer south east London. Clinicians locally have advised the PCTs that the current pattern of service provision cannot be maintained and without change services will become increasingly unviable, unable to meet national evidence-based guidelines and legislative requirements. The need for change is fuelled by the impact of initiatives such as Modernising Medical Careers and the European Working Time Directive, both of which will restrict the hours doctors are available for clinical work in future. There is an urgent need to address the way in which hospital services are provided, which will also require a change in out of hospital services. Some hospital services will have to be consolidated on fewer sites to ensure that patient safety and clinical outcomes can be significantly improved. At a time when PCTs in London are consulting on Healthcare for London: A Framework for Action, legal advice has been clear that PCTs should still proceed with consultation on proposals for service improvement where the case for change is urgent. The options for consultation in APOH are consistent with the direction of travel in Healthcare for London: A Framework for Action. NHS organisations are required to spend within their means. In outer south east London, the NHS Trusts and some PCTs are currently failing to do so. Without a reconfiguration of clinical services, the situation will not improve. All four hospital Trusts began 2007/08 with significant cumulative deficits, despite numerous and sustained attempts to control expenditure and the realisation of cost improvement programmes. All four are part of the Department of Health’s Financially Challenged Trusts programme. The Department required the development of a range of options to address the significant financial issues faced by the Trusts. The savings delivered through this work, together with the implementation of an APOH option, should make a significant contribution to addressing the health economy’s financial problems. The Consultation Document sets out the case for change in services in Bexley, Bromley, Greenwich and Lewisham and puts forward three options for service reconfiguration in the future. These options have been identified through an iterative process that began in December 2005. The process is described in Chapter 5 of the pre-consultation business case. Consultation options Clinicians locally have been at the heart of working up proposals for improving health services in outer south east London. Maintaining the status quo is not considered to be a clinically or financially viable option. The main difference in the options for change proposed is that whilst all four hospitals will remain, the mix of services on most sites will change under each option. The range of services to be provided at three of the hospitals is the same under each option; the exception is University Hospital Lewisham for which each option proposes different services. Borough Hospital This type of hospital would be open 24 hours a day and provide the following services: • Urgent Care Centre • Doctor-led medical assessment units for older people and for children • Outpatients and routine tests • Antenatal and postnatal care • Planned surgery (supported by critical care) to include day cases and inpatient stays • Orthopaedic centre • Rehabilitation beds for people recovering from a major condition, such as a stroke A borough hospital does not provide A&E, inpatient maternity services nor paediatric in-patient services. Medically Admitting Hospital This type of hospital would provide the hospital services described in Hospital type A. A medically admitting hospital would also include an A&E department that can admit patients who may need some emergency monitoring. A medically admitting hospital does not provide inpatient maternity services, nor inpatient paediatric services. Admitting Hospital This type of hospital would provide care for most seriously ill patients. Services would include: • Emergency care – A & E, receiving trauma, medical, surgical and paediatric emergencies and an urgent care centre • Complex planned and emergency surgery • A midwife-led maternity unit, but if there are complications there will be specialist doctor presence round-the-clock • A special unit for the most seriously ill babies • Inpatient and critical care services for children • Routine and specialist diagnostic tests • Outpatient services This will not provide elective surgical nor elective orthopaedic services The three options for change to be put forward for public consultation may be summarised as: Option 1 Borough hospital (Queen Mary’s Sidcup), Medically admitting hospital (University Hospital Lewisham), and Admitting hospitals (Queen Elizabeth Hospital, Woolwich and Princess Royal University Hospital, Bromley) by 2010/11 Option 2 Borough hospital (Queen Mary’s Sidcup) and Admitting hospitals (University Hospital Lewisham, Queen Elizabeth Hospital, Woolwich and Princess Royal University Hospital, Bromley) by 2010/2011 Option 3 Borough hospitals (Queen Mary’s Sidcup and University Hospital Lewisham) and Admitting hospitals (Queen Elizabeth Hospital, Woolwich and Princess Royal University Hospital, Bromley) by 2013/2014 at the earliest The options have also been informed by the findings of Professor Sir George Alberti, the national Clinical Director for Service Design and chair of the National Clinical Advisory Team. At NHS London’s invitation, Sir George carried out an independent review of the case for change in local services and reported on 5 December 2007. He supported a strong case for moving from four to either three or two admitting hospital sites for major emergency care. For the remaining hospital site(s), Sir George recommended an urgent care centre, daytime assessment services for paediatric and elderly patients and planned surgical services (for treatment other than emergency and complex surgery). Given local clinicians’ involvement in the process, the consensus they have reached on the clinical case for change and Sir George Alberti’s endorsement of the approach and the options for change, the executive of NHS London is satisfied that the APOH proposals represent the best opportunity for delivering improvements to health services in outer south east London. Pre-consultation business case The purpose of the pre-consultation business case is to set out the case for change with clear options for the future and assess the implications of each of the options. It also sets out the process followed, including the development of four specific clinical models (including the status quo). The business case underpins the decisions that have to be taken for consultation to begin. It does not pre-empt the outcome of the consultation - the consultation itself will inform the final decision on which option will be taken forward to improve care for the local population. The executive of NHS London has been working closely with the project team on the pre-consultation business case. Board members took the opportunity of discussing much of the contents of the business case at a meeting with members of the project team on 4 December – a summary of the discussion is appended. The options for change have been costed alongside the “do minimum” option. The business case represents excellent progress both in articulating the clinical and economic case for change and in demonstrating that the options for change are viable. However, further work needs to be done. The financial and activity modelling in the business case is based on the best information available to the APOH project team at a point in time, in this case early December 2007. The modelling will be updated during the consultation period, so that final decisions can be taken based on the most up-to-date information available. NHS London will continue to engage with the project team during the consultation period to firm up any remaining issues within the business case. At the current time, these issues include establishing with greater confidence the costs to the PCTs of increased out of hospital activity, reviewing the transitional costs as implementation plans are developed and exploring in greater detail the feasibility of the additional capacity needed under Option 3. However, the pre-consultation business case is recommended to the Board as being sufficiently robust to allow the PCTs to proceed to consultation. Next Steps A Joint Committee of PCTs (JCPCT) has been established. Its membership comprises of Bromley, Greenwich and Lewisham PCTs, Bexley Care Trust and West Kent PCT (to represent the people of north west Kent who use health services in the four outer south east London boroughs). The JCPCT meets on 18 December, when it is expected to approve proceeding to consultation on the proposals outlined in the Consultation Document. Formal consultation is planned to start on 7 January 2008 for a period of three months. A full programme of consultation events has been planned to accompany the consultation period. Once the consultation period has ended, Imperial College will analyse results and produce a report for an APOH Project Board meeting and the JCPCT. All responses received during the consultation period will be included in the analysis. The JCPCT is likely to meet to consider the Project Board’s recommendations in June 2008 to decide whether to support them, taking into account the needs of their populations and the impact on the wider health economy. As representative of the commissioning organisations, the JCPCT is responsible for making the final decision. Decisions on service changes are primarily a matter for the NHS locally and Ministers and the Department of Health are not involved in the decision- making process. The exception to this is if the local Overview and Scrutiny Committee (OSC) disagrees with proposals for change. The OSC can refer the proposal to the Secretary of State on two grounds: inadequate consultation with the OSC; and/or that the proposals are not in the interest of the local health service. The Secretary of State has signalled he would subsequently ask the Independent Reconfiguration Panel for formal advice on all contested service reconfigurations that have been referred by an OSC. In the case of the APOH clinical strategy, a Joint OSC has been established to cover the relevant populations (with representation from Bexley, Bromley, Greenwich, Lewisham, Lambeth, Southwark and Kent). The APOH project team has engaged with the Joint OSC regularly. Conclusion The executive of NHS London has been working closely with the project team for the APOH clinical strategy and will continue to do so to firm up any remaining issues with the business case. It believes that the proposals for formal consultation, including the Consultation Document, will result in effective engagement locally with patients, the public and their representatives. Therefore, the Board is asked to: • satisfy itself that the PCTs’ business case is sound, outlining any remaining issues to be addressed during the consultation period; and on that basis • agree plans to proceed to formal consultation on options for change as set out in the A Picture of Health Consultation Document. London Strategic Health Authority Meeting to discuss ‘A Picture of Health’ Pre-Consultation Business Case 4 December 2007 Present: George Greener Chair Paul Baumann Director of Finance and Performance Helen Cameron Project Director – A Picture of Health Ruth Carnall Chief Executive Malcolm Dennett Project team member Jo Farrar Director of Regulatory Operations Alastair Finney Head of Reconfiguration – Strategy and Commissioning Helen Lavan Board Secretary Hannah Rich Deputy Director of Strategy and Commissioning Simon Robbins Chief Executive, Bromley PCT Anthony Sumara Turnaround Director Mike Spyer Non-Executive Director Nick Ville Non-Executive Director Timothy Walker Non-Executive Director Apologies: Mike Bell Non-Executive Director Dawn Stephenson Non-Executive Director 1. A copy of the draft pre-consultation business case was received. The SHA were advised that Professor Sir George Alberti’s report was due to be published very shortly. It was agreed that it be circulated to Non Executive Directors. 2. The three emerging options for change in outer south east London are: option one: two fully admitting hospitals at BHT and QEH, one medically admitting hospital at UHL and one “borough” hospital at QMS, plus supporting out of hospital care; option two: three fully admitting hospitals at BHT, QEH and UHL and one “borough” hospital at QMS, plus supporting out of hospital care; and option three: two fully admitting hospitals at BHT and QEH, and two “borough” hospitals at QMS and UHL, plus supporting out of hospital care.” 3. The role of the SHA in this process was reiterated. The Board will be looking for assurance that: • The SHA has quality assured the consultation document • The SHA has supported the PCTs in the development of the business case and in doing so, are content that it is robust and fit for purpose. Change in outer south east London will provide a stable financial and physical platform to enable further change in line with Healthcare for London. 3. Significant issues to be addressed within the business case were listed in the papers and put forward through subsequent discussion at the meeting. Further analysis to be carried out might yet make one or more of the options less viable. • The benefits for patients should be made clear at the beginning of the document and reinforced where appropriate in the narrative; • Out of hospital investment and the programme for change needs to be stated early in the document; • Under option three, an assessment of the capital implications for King’s is needed and should be included in the case; • Under option three, further reassurance is needed that the financial implications of the additional out of hospital activity has been properly assessed, including any associated capital and transitional costs of double running; • The quality of the PCTs’ income and expenditure modelling needs improving – it appears to be inconsistent. It is possible that work to address this could affect the discounted cash flow figures and / or the overall analysis; • Assurance is needed on the strategic fit between APOH and SARK (the acute trusts’ project, with the support of NHS London’s Provider Agency, to address their financial challenges and identify a range of cross-cutting initiatives to realise savings). SARK does not require consultation and is not dependent on service reconfiguration; and • The business case should also flag up SARK2 – like SARK, though led by the PCTs, to identify a range of cross-cutting initiatives to realise savings. 4. The pre-consultation business case will be revised in the light of comments made and a version submitted to the SHA Board at its meeting on 19th December, together with a copy of the Consultation Document. The business case is a live document and will be subject to further review during the consultation period.