Consultation on A Picture of Health for outer south east London

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					Consultation on A Picture of Health for outer south east


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

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
   • 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

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

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.


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

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
                 Helen Lavan               Board Secretary
                 Hannah Rich               Deputy Director of Strategy and
                 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;
              option three: two fully admitting hospitals at BHT and QEH, and two
              “borough” hospitals at QMS and UHL, plus supporting out of hospital

           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
      • 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.

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