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					National Public Health Service for Wales            ASPECTS OF ACUTE SERVICES REDESIGN –
                                                       KEY MESSAGES FROM THE LITERATURE




Aspects of Acute Services
Redesign – Key Messages
from the literature




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                                                       KEY MESSAGES FROM THE LITERATURE



1          Summary of Key Messages from the Literature
1.1        Drivers for change
       The issue of Acute Service Redesign is pertinent to health economies across the UK,
        and many are reviewing their acute services with a view to improving sustainability


       There are a number of common drivers for acute service redesign; changing disease
        patterns – increasing numbers with chronic conditions, rising emergency admissions,
        outdated current configurations, implementation of European Working Time Directive
        and consideration of the evidence base in relation to volume and outcomes.

1.2        General points on service redesign
       There should be a focus on locally provided core services, with not all services
        available on all sites. It is anticipated that this is achieved through some of the
        following:

         Strengthening chronic disease management programmes in the community,
          primary care, intermediate setting
         Managed Clinical Networks – joint working between hospitals, well developed
          transfer arrangements
         Innovative approach to workforce redesign and extension of staff roles
         Separation of elective and emergency cases
         Development of ICT – use of telemedicine, electronic patient record and digital
          imaging transfer

       There is a decline in access to services with increasing distance from medical care.
        Rural patients in the UK are more likely to have advanced diabetic retinopathy, higher
        mortality from asthma, higher death rates from trauma and lower rates of access for
        angiography and revascularisation


       NHS Scotland proposes a model based on networks of rural community hospitals and
        Rural General Hospitals.

1.3        Emergency/Acute Care
       Innovative approaches to service design in relation to Emergency Care include; use of
        ambulatory care models, Emergency Care Networks, ‘See and Treat’ model and the
        use of medical assessment units alongside emergency departments


       Providing care through Clinical Networks as described in much of the literature will
        inevitably require the transfer of acutely ill patients at times. This should always be
        done following the Intensive Care Society Guidelines for the Transportation of the
        Critically Ill Adult


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       Workforce redesign and the extension of staff roles will be an essential part of any
        acute service redesign.


       Information and Communication Technology is a key aspect of service redesign.
        Telemedicine, the Electronic Patient Record and the digital transfer of images will be a
        vital part of working in an integrated way across community, intermediate and acute
        care, and in working as part of Clinical Networks


       Access to services, particularly in relation to public transport and NHS transport
        systems is key when any service redesign is considered

1.4        Management of chronic/long term conditions
       To date there has been limited systematic use by the NHS in Wales of GP based
        information on chronic diseases for planning purposes. Data collection as part of the
        Quality and Outcomes Framework could improve this.


       There is a move towards a more generic approach to management of long term
        conditions i.e. basic principles of management are the same regardless of the specific
        condition


       Key elements of an effective chronic disease management programme include; broad
        managed care programmes, targeting high risk people, sharing skills and knowledge,
        patient involvement in decision making, self management education, self monitoring,
        telemedicine and use of disease registers.


       Effective programmes can improve clinical outcomes and quality of care for people
        with chronic diseases, and ensure they are managed predominantly in the community
        setting, therefore reducing hospital admissions and attendances.




2          Background
The purpose of this document is to support the work currently being undertaken by the Mid
and West Wales Acute Services Reconfiguration Project Team and the NPHS Designed for
Life project team, by reviewing the current literature relating to aspects of acute service
redesign and pulling out the key messages. Alongside this, aspects relating to the management
of long-term conditions will also be considered.

The reasons for re assessing the way health services are designed in Mid and West Wales are
clearly set out in both the Designed for life Strategy1 and the Case for Change2 document.
Designed for Life outlines a 10 year strategy to deliver a world class health service in Wales
by 2015, and the Case for Change highlights the point that in order to achieve this for the
people of Mid and West Wales, the current uncertain and uneven delivery of care needs to

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change towards a system that ‘delivers high quality services as close to people’s homes as
possible’ balancing this with the safety and quality of care.




3          Methodology
The NPHS Library and Knowledge Management Service supported this piece of work by
undertaking a literature search. Keywords used were; medical assessment units, patient
admission, hospital admission, medical decision making, hospital configuration, hospital
reconfiguration, medical admission units, admission units, review, acute care. In addition to
this, relevant and reputable key websites were searched for reports and documents (See
appendix 1 for list of websites searched). Some snowballing from reference lists of key
documents was also carried out. Colleagues known to be undertaking relevant work were
contacted (e.g. for long term conditions).

The timeframe for the production of this document was extremely tight and the subject matter
extremely broad, it was therefore impossible to carry out a rigorous systematic review or to
review all the literature in relation to the key areas. Key reports e.g. those by Department of
Health, Welsh Assembly Government, Royal College Reports, NHS Scotland etc, and
evidence reviews were prioritised. It is the purpose of this report to highlight the key
messages and provide a platform for discussion and further review of specific areas if
necessary.




4          Drivers for Acute Service Redesign
The Wanless report confirmed that the current health and social services in Wales are not
sustainable and have to change3. Designed for Life warns that if change does not happen we
risk spreading resources too thinly, misusing and diluting clinical expertise, being unable to
recruit skilled professionals, services being overwhelmed by demand and specialist services
being too fragmented2. What became very clear early on in this piece of work is that these
problems are not unique to Wales and that health economies in England, Scotland and
Northern Ireland are facing similar challenges. Many areas are undertaking reviews of their
health services with a view to creating more sustainable services. Reviewing the work being
undertaken in other areas across the UK revealed common driving factors for the redesign of
acute services, and these are discussed below.

4.1        Changing disease patterns
Much of the literature emphasised the ageing nature of our society and the likelihood of
increasing life expectancies in the next 20-30 years4,5,13,14. With this demographic pattern, the
number of people with chronic conditions is also likely to increase. One third of adults in
Wales currently has at least one chronic condition (800 000 people) and it is estimated that
this will rise by 12% by 2014, with a 20% rise in those aged over 6511




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4.2        Rising Emergency Admissions
There has been a sharp rise in emergency admissions across the whole of the UK in recent
years7,9,10,11 placing increasing pressure on the acute sector, a rise of 22% in Wales in a
decade11. Two thirds of emergency medical admissions in Wales are as a result of a worsening
chronic condition or for patients who have an existing chronic condition. There is increasing
evidence that managing patients with chronic conditions effectively in primary, community
and intermediate care can prevent admissions and lead to higher levels of patient
satisfaction11,12

4.3        Outdated current configurations
It is now recognised that many of the current configurations of hospital services are not
sustainable2,4,5,6,7, and are often outdated4. In order to deal with changes in the workforce and
rising emergency admissions against the backdrop of changing disease patterns, there needs to
be a move towards proactive, local, integrated care for chronic conditions with specialised,
episodic care for acute conditions when necessary5.

4.4        European Working Time Directive
In the literature, the European Working Time Directive was repeatedly cited as a powerful
driving force in looking at the way services are provided1,2,4,5,6,7,8,9. This directive, due to be
implemented in 2009, affects the number of hours junior doctors can work (48 hour week). If
current working patterns stay the same a big increase in the number of doctors would be
needed to run a 24 hr service. This would provide particular problems for smaller hospitals
with limited staff4,5,8. In relation to the E.W.T.D, Sir John Temple in his Securing Future
Practice report notes40;

‘..Limitations on medical staff time is a powerful lever for service redesign…clinical
situations for which triage and transfer arrangements are appropriate must be made on the
basis of patient safety, balancing issues of speed of access to specialised medical services
against what it will be possible to provide and sustain locally. We recommend this is
addressed urgently and realistically, in many situations the status quo cannot survive’..40

Some innovative solutions to this problem are being considered, one of which is the Hospital
at Night project. In this model multidisciplinary teams work in shifts overnight to manage the
clinical needs of patients at night. Initial evaluations of this project are encouraging27.

4.5        Relationship between volume and outcomes
There is now good evidence that centralising some highly specialised services into fewer sites
provides a safer service with better outcomes for patients4,5,15,16. Some examples of these
services include paediatric cardiac surgery, vascular surgery, cardio thoracic surgery and some
cancer surgery4,5,15. This has been a clear and straightforward driver to redesign some
specialist services to ensure the best outcomes for patients. There is good evidence however to
show that routine, common procedures and conditions can be managed in smaller more local
hospitals4,5,15,16. The evidence appears to show that for common procedures clinicians need to
‘undertake a minimum number to maintain their skills but thereafter there is no great clinical
benefit in specialisation or need for it’5.

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5          Key Themes arising from the literature on
           Acute Service Redesign
The next part of this report will look in detail at the key features of service redesign that have
been considered and implemented across the UK

5.1        Keeping the NHS Local
‘Keeping the NHS local’ (England) sets a clear direction of travel for the NHS when
considering expansion and service redesign. It focuses on smaller hospitals and has 3 core
principles:


    1. Developing options for change with people not for them
    2. Focus on redesign not relocate
    3. Taking a whole systems view

The document is clear that the majority of health services should be provided locally and with
imaginative approaches to service redesign, smaller hospitals can be sustainable. It describes
the problems that have occurred with reconfigurations in the past when, faced with competing
pressures two smaller hospitals have merged. The report states that there is evidence that this
approach does not necessarily deliver the expected benefits. ‘The link between volume and
outcome for many surgical procedures is often overestimated, the financial benefits do not
always materialise and access is reduced with a greater burden on older and poorer people’4. It
sees an emphasis on core services and joint working between organisations as the key to
maintaining local access. The report sets out the principles, which all health communities are
expected to apply when developing service models and the Independent Reconfiguration
Panel will use it whenever they form a judgement on a proposed service reconfiguration.

In relation to local access to services, a consultation exercise conducted as part of the National
Beds Inquiry found support from the respondents (487) for the provision of care close to
home. Respondents had the choice of three models; 1. Maintain current direction, 2. Acute
bed focused service 3. Care closer to home. There was almost universal support for the care
closer to home model that advocated a major expansion of community health and social care,
with acute services focused on rapid assessment42

The recommendations in relation to service redesign set out in ‘Keeping the NHS Local’ are
supported by two additional configuring hospitals evidence files, describing the evidence base
and examples of service models16,17. The document describes 4 different models of service
redesign aimed at smaller hospitals with a view to improving sustainability (See Appendix 2).
The models are being piloted at different sites across England, there does not appear to be any
evaluation reports from these pilots available as yet. Some key elements of some of the
models are as follows:


       Integration of primary, secondary and intermediate services
       Senior clinicians at front end of emergency care
       Rapid diagnostics
       Extended working day. Strong day/night differentiation

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         Nursing practitioners as first line cover
         Local acute assessment separate from treatment services, with telemedicine links to
          local acute hospital for joint assessment and transport links to larger centre
         Acute medical admission supported by critical care, with no emergency surgical
          admissions – surgery working as a network with access to surgical opinion on call
         Services working as part of clinical networks with well developed transfer
          arrangements in place
         Ambulatory care providing services for diagnosis, outpatients, elective surgery, urgent
          treatment other than for seriously ill patients, low dependency care, chronic disease
          management and intermediate care.

‘Keeping the NHS Local’ emphasises the need for local access to core services, with an
acceptance that not every service can be provided on every site. The document proposes
integrating services, taking a whole systems approach, working within clinical networks,
using innovative approaches to the workforce and making full use of telemedicine. It suggests
that using these approaches can provide sustainable solutions for smaller hospitals and can
ensure care is delivered as locally as possible where appropriate.

5.2         The Kerr Report
‘Building a Health Service fit for the Future’ is the new National Framework for Service
Change in Scotland. The National Framework Advisory group was chaired by Professor
David Kerr, MSP. The report sets out a 20 year plan for NHS Scotland and was developed
with public engagement and from a series of reports from multidisciplinary action teams who
looked into specific issues such as elective care18, unscheduled care9, remote and rural
access19, volume and outcomes15 and long term conditions20.

The report describes similar drivers for service change as those described above and is
consistent with ‘Keeping the NHS Local’ in its vision to provide the majority of care locally.
The proposals of the framework include the following


         Systematic approach to management of long term conditions – management at home
          or in community where possible
         Multidisciplinary teams in community casualty departments providing vast majority
          of unscheduled care – networked by telemedicine to emergency units
         Separating planned care from urgent cases, treating day surgery as the norm, enabling
          better community based access to diagnostics
         Concentrate specialised or complex care on fewer sites to secure clinical benefit or
          manage clinical risk
         Develop networks of rural hospitals and establish Clinical School for Rural Health
          Care

The Framework also describes a model for the management on unscheduled care based on
four levels (See appendix 3)




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5.3        Health services for rural and remote communities
The evidence base in relation to rural and remote communities shows that there is a decline in
access to services associated with increasing distance from medical care, and poorer health
outcomes of remote rural residents19,21,22. Rural patients in the UK have been found to be
more likely to have advanced diabetic retinopathy, higher mortality from asthma, higher death
rates from trauma and lower rates of access for coronary angiography and revascularisation 22.
Mungall notes that the increasing trend towards centralisation of services disproportionately
impacts on those living in rural and remote areas, in particular those with low incomes, poor
access to transport, the elderly and disabled. Mungall goes on to cite a study of cancer patients
in remote Scotland and their experience of accessing specialist care. The patients spent 22
days (13% of their remaining life) travelling to or in hospitals. The effect of centralisation can
therefore be that the costs saved by the health service are passed to the patients22.

Mungall supports the models set out in ‘Keeping the NHS Local’ as a way of continuing to
provide high quality services to rural communities, by such initiatives as linking community
emergency units to larger central emergency units by videoconference. He cites team
working, networks, IT, improving rural transport, outreach clinics, potential rural career
pathways and equitable funding as other key areas that are important to consider.

The National Service Framework for Service Change in Scotland Rural Access Action Team
produced a report on the future of providing health care to rural and remote communities in
Scotland. The report describes a model where Primary Care Practitioners will be skilled up to
provide screening, assessment, diagnostic and treatment services in the primary, intermediate
or community hospital setting. The models sees community hospitals as being the first port of
call for the majority of care in the rural setting, providing A&E services staffed by Emergency
Nurse Practitioners supported by local GP’s. Initial care for MI’s, COPD/asthma
exacerbations and strokes could be provided in the community hospital with patients being
transferred as necessary. The report also states that community hospitals could provide
stabilisation prior to transfer for major trauma. Other important services that the model
proposes could be provided from the community hospital include:


       Access to diagnostics
       Midwife led maternity unit
       Palliative care
       Out patients
       Specialist clinics
       Telemedicine
       Rehabilitation/Convalescence
       Alcohol Detoxification



In this model, the community hospitals would be linked to Rural General Hospitals through
Managed Clinical Networks, ensuring safe and effective pathways of care. Rural General
Hospitals would provide:




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         Emergency medical care: triage, diagnosis, resuscitation/stabilisation and treat where
          possible, transfer when necessary
         Locally based elective care: diagnosis, treatment or transfer
         Care for chronic illness: care of the elderly, stroke, diabetic, renal dialysis

In order to deal with the 5% of out of hours activity that is a genuine emergency, the model
advocates ensuring there is a resilient community with the following in place:


         Immediate access to central, emergency triage and dispatch organisation
         First responder scheme. Trained people from local community
         Professional emergency response graded to need
         Patients transferred to nearest diagnostic centre capable of defining condition and
          stabilising patient. Could either be Rural General Hospital or an enhanced rural
          community hospital
         Agreed response times for above

In addition to describing the above model of rural and remote health services, the Action
Team report emphasises the importance of a skilled and competent workforce. It focuses
specifically on the importance of achieving the right balance of generalists and specialists and
calls for a Rural and Remote component in National undergraduate Training schemes and the
development of post graduate training schemes to support the development of remote and
rural practitioners19

5.4          Emergency Care
Rising emergency admissions and the burden this places on Emergency Departments has been
discussed as a key driver for service redesign. This report has also already discussed
Scotland’s approach to the provision of unscheduled care (see appendix 3) in particular for
rural and remote communities. The models from Keeping the NHS Local also provide some
examples of innovative ways to deliver emergency care. Some additional key themes that
have emerged from the literature in terms of redesigning emergency care are as follows:


         Taking a whole systems view of emergency care. Strengthening the primary care
          management of long-term conditions to avoid unnecessary emergency admissions.
          Placing primary care out of hours services alongside emergency units4,5,9
         Using ambulatory care models such as walk in centres and minor injury units,
          community hospitals, and intermediate care to deal with minor illness/accidents and
          manage long term conditions4,19,23
         Providing care through Emergency Care Networks, integrating primary care, acute
          trusts, social services, local authorities, ambulance trusts, pharmacies, mental health,
          voluntary sector, NHS direct and Out of Hours Services23
         Using models such as ‘See and Treat’. This innovation has transformed A&E
          departments in England. It is based on the principle that the first clinician to see the
          patient can assess, treat and discharge the patient with minor complaints. There are
          dedicated staff to See and Treat and separate staff to deal with more urgent cases23,24
         Admitting acutely ill patients to medical assessment units can achieve a reduction in
          the number of emergency hospital admissions25,26

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5.5        Transfer acutely ill patients
If future hospitals services are to function as part of Managed Clinical Networks, then it is
anticipated that at times acutely ill patients will have to travel between hospitals for treatment.
‘Quality Critical Care’28 recommends critical care be provided as part of critical care network
and accepts that transfers will sometimes be necessary28. However it recognises that transfers
can put patients at risk and should be minimised and undertaken to the highest standards. It
recommends that all transfers of critically ill patients should be undertaken following the
Intensive Care Guidelines for the Transportation of the Critically Ill Adult Patient, the current
gold standard for care of patients requiring transport. See Appendix 4 for a summary of these
guidelines.

Three trials comparing transfer of patients with acute MI for primary angioplasty to a
specialist centre to usual care (treatment with thrombolysis in local centre) found that patient
outcomes improved for patients transferred for primary angioplasty. All three trials concluded
that transfer of this group of patients for this purpose was safe30,31,32

One study looked at transfer of patients with major trauma in Western Australia comparing
rural transfers with urban34. The study quotes four other studies supporting the regionalisation
of trauma care35-39, with one study by Sampalis et al noting that severely injured patients have
better outcomes when transported to a trauma centre rather than being stabilised at less
specialised facilities prior to transfer39. However it was noted that the Sampalis study was
done in largely urban areas with mean transfer times of 32.8 min for the transferred and 42.6
min for the direct transport patients. Due to the large geographical area involved in the
Western Australia study, the median transfer time was 9h 12m for the rural group, with most
patients being stabilised at a local hospital before transfer, with most transfers by air. This
makes it difficult to generalise the findings of this study to the UK setting, however it is
interesting to note that motor vehicle accidents were the most common cause of major trauma,
with head injury and intrathoracic trauma being the most common injuries.

5.6        Workforce
Issues’ relating to workforce, skill mix and the extension of staff roles was an overwhelming
theme from the literature and was cited as an important consideration in almost all of the
papers discussing aspects of services redesign4,5,6,7,9,10,16,17,19,23,24,27,41. It is clear from the
literature that any future service redesign will have to consider the development of the
workforce as a priority.

‘Keeping the NHS Local’4 and its supporting configuring hospitals evidence files 16,17
describe the evidence base and a range of pilot studies in relation to workforce redesign. A
range of innovative strategies are described that aim to address the centralising pressures felt
by smaller hospitals through:


       New and extended roles for doctors, nurses and other clinical staff
       Shifting from traditional medical firm based to team based working
       Exploring new ways to manage the hospital at night27
       Achieving the right balance of care from generalists and specialists



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There are many examples of workforce redesign and extended staff roles in the literature.
Many of these are innovative solutions currently being piloted and evaluated. The following is
a list of examples:


         Emergency Care Practitioners (usually specially trained paramedics/nurses) supporting
          the Emergency Care Network in a range of settings (community, intermediate, acute)23
         Nurse Practitioners as first on call tier cover – especially at night4
         Medical assistants to reduce workload on doctors4
         Nurse led walk in centres, minor injury and minor surgery units16,17
         Physiotherapy practitioners treating minor injuries17
         GP’s with specialist interest working in Primary Care Resource Centres providing a
          broad range of outpatient sessions, diagnostic and surgical procedures4

An aspect of the medical workforce design that was discussed in some of the literature is the
balance between generalists and specialists4,5,8,9,19,22 especially in relation to rural and remote
communities where generalist skills are often highly valued5,19,22. Much of the literature noted
the trend for hospital doctors to become more and more specialised4,5,22. ‘Keeping the NHS
Local’ notes that there is now a growing recognition among professional bodies that the
balance between generalists and specialists needs to be adjusted, and that new roles for
hospital clinicians are placing a premium on generalists skills in assessment and diagnosis4.
This is currently being considered by some medical colleges in relation to specialist training4.

5.7         Information and Communications Technology
The development of ICT in relation to service redesign was another overwhelming theme
from the literature and was repeatedly cited as a key aspect of service redesign4,5,8,9,16,17,21,41.
One of the configuring hospitals evidence files report a range of national and international
studies on the use of telemedicine. There appears to be evidence to support the use of
telemedicine in the following areas16:


         Linking remote emergency units to larger hospitals
         Use in GP surgeries, walk in centres, community hospitals and patients homes can be
          successful in bringing acute services out of hospitals and into local communities
         Remote consultations in orthopaedics, neurology, psychiatry and cardiology
         Videoconferencing as part of clinical networks in pathology, cancer and psychiatry
         Diagnosis of fracture by nurses in local centres, supported remotely by doctors

The literature highlights the development of the Electronic Patient Record and the Transfer of
Digital Images for diagnostic purposes (via PACS) as other areas that need to be considered
alongside any proposals for services redesign.

The literature does note that telemedicine is not being held up as a panacea that can solve all
the issues relating to health service design, and cannot replace the clinician in many situations.
However the growing body of evidence suggests it can play a vital role in many aspects of
health care provision4,5,16,17



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5.8        Transport
Much of the literature discussed the importance of considering access to services for patients
when considering service redesign. A key part of access to services is transport and this is
especially relevant for rural and remote communities and for those patients who rely on public
transport. The literature highlighted the following key points in relation to transport;


       Public transport should be aligned with health services6,33
       Ensuring appropriate patient transport is available 7 days a week to avoid delaying
        patient discharges
       There should be an effective non-emergency transport service/medical taxi service;
        ensuring fully equipped ambulances staffed by paramedics are only used for true
        emergencies33.
       Consideration could be given to using NHS transport for social indications e.g. visiting
        for relatives, especially for rural and remote communities41.
       The role of ambulance staff could be enhanced so that some patients are discharged
        home after treatment by ambulance staff and some taken to local community
        assessment facilities/ intermediate care9


6          Long term conditions
Rising emergency admissions and changing disease patterns have already been discussed as
potential drivers for service redesign. It has also been highlighted that many emergency
medical admissions in Wales are related to worsening chronic conditions. Improving the
management of chronic conditions, also known as long term conditions, is one of the key
aspects described in most of the literature on service redesign. It is anticipated that by
improving the management of chronic conditions in the primary care, community and
intermediate settings, those with chronic conditions will be less likely to be admitted as
medical emergencies and will have much more of their care provided locally4,5,11,12,20

The ‘Profile of long term and chronic conditions in Wales’ notes that one third of adults in
Wales (800 000 people) have at least one chronic condition. Intensive users of inpatient
services have 3 chronic problems, on average, and this group makes up 6% adults11. The
profile estimates a 12% increase in those with at least one chronic condition by 2014, and an
increase of 20% in those aged 65 and over.

The profile highlights that there is a limited amount of data currently available in Wales on
the prevalence of chronic diseases, and that it is currently difficult to obtain exact figures on
the number of people with particular conditions. To date there appears to have been little
systematic collection of data at a GP practice level to inform the NHS, although this will
hopefully change in the future due to the new GMS contract and the collection of data for the
Quality and Outcomes Framework11.

In terms of the management of chronic diseases there appears to have been a recent move
away from a condition specific approach to chronic disease management, as set out in most of
the NSF’s, and a move towards a more generic approach to management i.e. the basic
principles of long term condition management are the same irrespective of the specific
condition20. In a review of the evidence on effective service models in chronic disease
management, Dr Webb reviews the evidence base on a number of broad chronic care
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programmes12. The most commonly cited of these programmes are Kaiser, Evercare and
Pfizer. Originally developed in the US, these programmes are now being piloted in England
and there is some evidence that these programmes ‘improve quality of care, clinical outcomes
and reduce the use of healthcare resources’12. Some of the key features of these programmes
are; targeting high risk patients, care in the least intensive setting, self care and patient
education, good information systems, proactive management and clear staff roles. The
evidence review report has detailed information on each programme12.

The evidence review revealed key elements that should be included if one was designing a
new programme for the management of long term conditions12:


        Broad managed care programmes
        Targeting high risk people
        Sharing skills and knowledge
        Patient involvement in decision making
        Self management education
        Self monitoring and telemedicine

There was also good evidence that the development of disease registers can improve patient
care. In light of the evidence for using disease registers and targeting high risk people as part
of an effective programme for the management of long term conditions, there is clearly a need
to tackle the current data collection systems at a GP level and to use GP data in a consistent
and systematic way


7          Discussion
Common drivers have lead health communities across the UK to review their acute services
and there are a range of key themes arising form the literature on acute service redesign. In
order to adapt to the drivers for change and provide sustainable services that are locally
accessible, health services will need to; integrate, strengthen primary care, provide
management of long term conditions in the community setting, work as part of Clinical
Networks to provide a range of routine and specialised services, develop innovative staff roles
and exploit the potential of technology4,5,41. The examples of service models in the literature
do not propose that every service is provided on every site but that patients are treated locally
where possible and transferred within the network for treatment where this is indicated, as part
of local protocols and care pathways4,5,16,17. In addition, the literature notes that health services
in rural and remote areas may need to specifically consider the local context in relation to
developing service models for redesign8,19, with transport links to and between hospitals also
needing careful consideration6,9,33,41.

Any one of the areas discussed in this report could be reviewed in considerably more depth
and it is anticipated that this paper will stimulate discussion, highlight areas for further work
and provide guidance for those considering undertaking reviews of current services.




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8          References
1. Wales. Welsh Assembly Government. Designed for Life: creating world class health and
social care for Wales in the 21st Century. Cardiff: Welsh Assembly Government; 2005.
Available from: www.wales.nhs.uk/documents/31672.pdf [Accessed: 13/2/2006]

2. NHS Wales. Building local, safe and sustainable services for Mid and West Wales: the case
for change. 2005. Available from:
http://www.healthchallengepembrokeshire.co.uk/objview.asp?object_id=17 [Accessed:
13/2/2006]

3. Wanless D. The review of Health and Social Care in Wales: the report of the Project Team
advised by Derek Wanless. [Cardiff: Welsh Assembly Government]; 2003. Available from:
http://www.wales.gov.uk/subieconomics/content/hsc/review-e.pdf [Accessed: 13/2/2006]

4. Department of Health. Keeping the NHS local: a new direction of travel. London: DoH;
2003. Available from: http://www.dh.gov.uk/assetRoot/04/08/59/47/04085947.pdf [Accessed:
13/2/2006]

5. NHS Scotland A national framework for service change in the NHS in Scotland: building a
health service fit for the future. [Edinburgh: Scottich Executive]; 2005. Available from:
www.scotland.gov.uk/Publications/2005/05/23141307/13104 [Accessed: 13/2/2006]

6. Darzi A. Acute Services Review – Hartlepool and Teesside. Stockton on Tees: North Tees
Primary Care Trust; 2005. Available from:
http://www.northteespct.nhs.uk/publications/acuteservicereview/ [Accessed 1/3/2006]

7. Joint Consultants Committee. Organisation of acute general hospital services. London:
Joint Consultants Committee; 1999.

8. Academy of Medical Royal Colleges. Rural Access Working Group. Centralisation and
specialisation of hospital services: bigger is not necessarily better for rural and remote
communities. 2005. ARCW(05)14 The trend towards centralisation of hospital
services2005oct final.doc

9. NHS Scotland National Advisory Group. A framework for the sustainable provision of
unscheduled care. 2005. Available from:
http://www.show.scot.nhs.uk/sehd/nationalframework/Documents/unschedcare/UnschedCare
240505.pdf [Accessed 1/3/2006]

10. Royal College of Physicians of Edinburgh, Royal College of Physicians and Surgeons of
Glasgow. Scottish Intercollegiate Working Party on Acute Medical Admissions and the
Future of General Medicine. A review of professional practices in Scotland with
recommendations for debate and action. Edinburgh: Royal College of Physicians of
Edinburgh; 1998.

11. National Public Health Service, Welsh Assembly Government. A profile of long-term and
chronic conditions in Wales. Cardiff: NPHS; 2005. Available from:
http://www.wales.nhs.uk/sites/documents/368/Prevalencew.pdf [Accessed: 13/2/2006]



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12. National Public Health Service, Welsh Assembly Government. Overview of the evidence
on effective service models in chronic disease management (Draft). Cardiff: NPHS; 2005.

13. National Public Health Service for Wales. Dependencies and expectations. Cardiff:
NPHS; 2005. Available from:
http://www2.nphs.wales.nhs.uk:8080/DesignedforLifeDocs.nsf/85c50756737f79ac80256f270
0534ea3/64b346ea0ab00f67802570d60038355c/$FILE/Dependencies%20and%20Expectatio
ns%20Final%2024Oct.doc [Accessed: 13/2/2006]

14. National Public Health Service for Wales. Drivers to services. Cardiff: NPHS; 2005.
Available from:
http://www2.nphs.wales.nhs.uk:8080/Designedforlifedocs.nsf/Main%20Frameset?OpenFrame
Set&Frame=Right&Src=%2FDesignedforlifedocs.nsf%2F61c1e930f9121fd080256f2a004937
ed%2F8025706f003aabe6802570d1003fc662%3FOpenDocument%26AutoFramed
[Accessed: 13/2/2006]

15. Murray GD, Teasdale GM. The relationship between volume and health outcomes: report
of Volume/Outcome Sub-Group to Advisory Group to National Framework for Service
Change, NHS Scotland. 2005. [Available from:]
http://www.show.scot.nhs.uk/sehd/nationalframework/Documents/VolumeOutcomeReportWe
bsite.pdf [Accessed 1/3/2006]

16. Department of Health. The configuring hospitals evidence file: Part one. London: DoH;
2004. Available from: http://www.dh.gov.uk/assetRoot/04/08/60/82/04086082.pdf [Accessed
1/3/2006]

17. Department of Health. The configuring hospitals evidence file: Part two. London: DoH;
2004. [Available from:]
http://www.changeagentteam.org.uk/_library/docs/comhosp/documents/Configuring%20hospi
talsPart%202.pdf [Accessed 1/3/2006]

18. NHS Scotland National Framework for Service Change. Elective Care Action Team Final
report. Edinburgh: Scottish Executive; 2005. Available from:
http://www.show.scot.nhs.uk/sehd/nationalframework/Documents/electivecare/Electivecare22
0505.pdf [Accessed 1/3/2006]

19. NHS Scotland National Framework for Service Change. Rural Access Action Team Final
report. Edinburgh: Scottish Executive; 2005. Available from:
http://www.show.scot.nhs.uk/sehd/nationalframework/Documents/remoterural/Final%20Draft
170505.pdf [Accessed 1/3/2006]

20. NHS Scotland National Framework for Service Change. Long Term Conditions Action
Team Final Report. Edinburgh: Scottish Executive; 2005. Available from:
http://www.show.scot.nhs.uk/sehd/nationalframework/Documents/electivecare/Electivecare22
0505.pdf [Accessed 1/3/2006]

21. Buchan T, Davies P. A review of the literature: access and service models in rural health.
Newtown: Institute of Rural Health; 2005. Available from: http://www.rural-
health.ac.uk/publications/Rural_Health_2_Eng.pdf [Accessed 1/3/2006]



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22. Mungall IJ. Trend towards centralisation of hospital services and its effect on access to
care for rural and remote communities in the UK. Rural and Remote Health: 2005; 5(2):
Article no. 390. Available from: http://rrh.deakin.edu.au [Accessed: 13/2/2006]

23.Alberti G. Transforming Emergency Care in England. London: Department of Health;
2004. Available from:
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidanc
e/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4091775&chk=9mgn5R
[Accessed 1/3/2006]

24. Parker L. Making See and Treat Work for Patients and Staff. London: NHS Modernisation
Agency, Emergency Services Collaborative; 2004.

25. Cole A. Clinical management. Where medicine meets management. Health Serv J.
2004;114(5908):28-9.

26. Wald D et al Medical assessment units: a realistic solution? British Journal Health Care
Management. 2001; 7 (7): 273-277.

27. Department of Health. The implementation and impact of Hospital at Night pilot projects.
An evaluation report. London: Department of Health; 2005. Available from:
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidanc
e/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4117968&chk=iZm%2BfA
[Accessed 1/3/2006]

28. Critical Care Stakeholder Forum. Quality critical care: beyond ‘Comprehensive Critical
Care’. London: Emergency Care Team; 2005. [Available from:]
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidanc
e/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4121049&chk=C2CJv3
[Accessed 1/3/2006]

29. The Intensive Care Society. Guidelines for the transport of the critically ill adult,
Standards and Guidelines. London: The Society; 2002. [Online] [Accessed: 13/2/2006]30.

30. Widimsky P, Groch L, Zelizko M, Aschermann M, Bednar F, Suryapranata H. Multicentre
randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs
combined strategy for patients with acute myocardial infarction presenting to a community
hospital without a catheterization laboratory. The PRAGUE study. Eur Heart J. 2000
May;21(10):823-31.

31. Grines C et al. A randomized trial of transfer for primary angioplasty versus on-site
thrombolysis in patients with high-risk myocardial infarction: the Air Primary Angioplasty in
Myocardial Infarction study. J Am Coll Cardiol. 2002;39(11):1713-9.

32. Moon JC, Kalra PR, Coats AJ. DANAMI-2: is primary angioplasty superior to
thrombolysis in acute MI when the patient has to be transferred to an invasive centre? Int J
Cardiol. 2002 Oct;85(2-3):199-201.

33. BMA Cymru Wales ‘Looking back from the future’: The shape of the hospital network in
2015. Cardiff: BMA; 2006


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34. Gupta R, Rao S. Major trauma transfer in Western Australia. ANZ J Surg.
2003;73(6):372-5

35. Mullins RJ et al. Outcome of hospitalized injured patients after institution of a trauma
system in an urban area. JAMA 1994;271(24):1919-24.

36. Shackford et al Impact of a trauma system on the outcome of severely injured patients.
Arch. Surg 1987; 122 (5): 523-7.

37. West JG, Trunkey DD, Lim RC. Systems of trauma care. A study of two counties. Arch
Surg. 1979;114(4):455-60.

38. Cales RH. Trauma mortality in Orange County: effect of implementation of a regional
trauma system. Ann. Emerg. Med 1984; 13: 1-10

39. Sampalis JS, Denis R, Frechette P, Brown R, Fleiszer D, Mulder D. Direct transport to
tertiary trauma centers versus transfer from lower level facilities: impact on mortality and
morbidity among patients with major trauma. J Trauma. 1997;43(2):288-95; discussion 295-6.

40. Scottish Executive. Short-Life Working Group. Securing future practice: shaping the new
medical workforce for Scotland. Edinburgh: Scottish Executive; 2004. Available from:
www.scotland.gov.uk/publication/2004/06/1954/38403 [Accessed: 13/2/2006]

41. The Scottish Office. Acute Services Review Report. Edinburgh: Scottish Office; 1998.
Available from:
 www.scotland.gov.uk/deleted/library/documents5/acute-00.htm [Accessed: 13/2/2006]

42. Department of Health. Shaping the future: long term planning for hospitals and related
services. Response to the consultation exercise on the findings of the National Beds Inquiry.
London: DoH; 2001. Available from:
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidanc
e/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4009394&chk=%2BCzyoH
[Accessed: 13/2/2006]




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9          Appendices
9.1        Appendix 1 – List of Key Websites Searched
       Department of Health                  http://www.dh.gov.uk/Home/fs/en

       NHS Modernisation Agency              http://www.wise.nhs.uk/cmswise/default.htm

       Scottish Executive Health Department http://www.scotland.gov.uk/Topics/Health

       Institute of Rural Health (Wales)     http://www.rural-health.ac.uk/

       British Medical Journal               http://bmj.bmjjournals.com/

       Scotland Office                       http://www.scotlandoffice.gov.uk/

       Rural and Remote Health               http://rrh.deakin.edu.au/home/defaultnew.asp

       Welsh NHS Confederation               http://www.welshconfed.org

       Welsh Assembly Government             http://www.wales.gov.uk

       Royal College of Physicians           http://www.rcplondon.ac.uk/

       Intensive Care Society                http://www.ics.ac.uk/




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9.2          Appendix 2 – Examples of Models of Service Redesign from
             Keeping the NHS Local4

Model 1 - Emergency medical and surgical care using new
approaches to staffing
         The proposed service model for the centre enables 24 hour emergency access to medical and
          surgical care, with relatively small numbers of trainee and career grade doctors and consultant
          medical staff.

         The approach demonstrates the power of combined workforce and service redesign. The
          hospital model depends heavily on integration of primary, secondary and intermediate care
          services to support quality patient care. This is being developed at the Central Middlesex
          Hospital in North London.

Key Model Elements
Offers:

          A&E with unselected admission

          New ways of working

          • unified general medicine and A&E

          • senior front end/rapid diagnostics

          • surgeons operating as unified team

          • extended day and strong day/night differentiation

          • nursing practitioners providing first-line cover for acute patients

          Supported by whole system

          • well-developed transfer arrangements

          • elective and emergency surgery as part of a network

Model 2 - Emergency medical care and elective surgical care
         A model of A&E access and emergency medical care being offered in the absence of 24 hour
          resident surgical cover, but with critical care. The model relies on effective joint working
          across a number of acute hospital sites. Deploying resources from all sites supports the
          viability of services on each site.

         This approach is being implemented at Bishop Auckland Hospital in County Durham, working
          in partnership with University Hospital of North Durham and Darlington Memorial Hospital.




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Key Model Elements
Offers:

          A&E with unselected admission

          • acute medicine – locally defined criteria for medical patients

          • no emergency – only elective surgical patients

          New ways of working

          • nursing provides first line cover to post operative patients

          Supported by whole system

          • on site critical care as part of network with well developed transfer arrangements

          • surgery working as a network enabling access to a surgical opinion on call

Model 3 - Local emergency unit
         In this model unselected patients receive rapid assessment in a local unit, with doctors from
          the nearest acute hospital site advising remotely via a telemedicine link. Based on this
          assessment, patients requiring more intensive acute care would be transferred to the acute
          hospital site for direct admission to wards, avoiding the need for a further wait in A&E. Local
          stakeholders in Penzance are developing this model for implementation in West Cornwall
          Hospital.

         This model builds on the experience of the telemedicine pilots established by the Scottish
          Telemedicine Action Forum. In one of the pilots, all fourteen community A&E departments in
          Grampian region are using videoconferencing facilities to enable the general practitioners and
          highly trained nurses based in the community hospitals to seek specialist advice from the main
          hospital in Aberdeen. Additional posts were put in place in the A&E department in Aberdeen
          Royal Infirmary to enable the additional work to be managed effectively. When patients are
          discussed using the telemedicine link the referral rate has been reduced by between 70 and 80
          per cent. Studies show that patient satisfaction with the service is extremely high.

Key Model Elements
Offers:

          Local acute assessment

          • Fast track step up/step down

          • Potential for wide range of ambulatory care elements

          New ways of working

          • Joint assessment by local clinical staff and remote specialists

          • Nursing and other non medical practitioners providing first line cover

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        • Software driven escalation protocols

        Supported by whole system

        • Linked to larger centre, primary care and ambulance services

        • Fast digital links to remote centre

Model 4 - ‘Ambulatory care plus’
   We have stated that the small hospital models outlined above can bridge the gap between large
    acute hospitals and ambulatory care. But ambulatory care itself is an area which is already proving
    to have real potential as a setting for delivery of a wide variety of services, with the advent of
    ‘ambulatory care plus’.

   ‘Ambulatory care plus’ is a general term used to describe models of care that build on existing
    primary and community services, such as Walk-in Centres, advanced access surgeries and
    community hospitals. These services already exist in a number of areas, and such services may
    include facilities for

         consultation, investigation and diagnosis

         most outpatient services

         many planned surgical procedures

         urgent treatment for patients other than the most seriously ill (i.e. for all non-999 cases,
          but could include category C ambulance patients)

         low-dependency inpatient care

         chronic disease management

         Intermediate care.




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9.3        Appendix 3 – Levels of Unscheduled Care, NHS Scotland’s
           National Framework for Service Change5
Level 1 – Community provided services such as GP Out of hours, Ambulance Service, NHS
Direct

Level 2 – Locally provided assessment and treatment services, such as minor injuries, illness
assessment, with some diagnostic facilities

Level 3a – Providing core admitting services – general surgery, general medicine,
orthopaedics

Level 3b – Providing sub specialised services – Vascular surgery, Urology, Burns and Plastic
surgery, interventional cardiology

Level 4 – Limited number of facilities providing highly specialised services e.g. neurosurgery




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9.4        Appendix 4 – Intensive Care Society, Summary                                      of
           Guidelines for the transport of the critically ill adult29
       Critical Care Networks and transfer groups have been established according to
        national directives

       There is evidence that the outcome of critically ill patients is improved by the use of
        dedicated transfer teams. Critical Care Networks should therefore consider the
        development and use of dedicated transport team

       All acute NHS hospitals must retain the ability to resuscitate, stabilise and transport
        critically ill patients. Hospital transport teams should be developed. These should be
        appropriately trained, resourced and supervised. A senior clinician and nurse with each
        hospital should be responsible for the organisation and development of teams.

       Each hospital should have a designated consultant available 24 hours a day to
        organise, supervise and where necessary undertake all inter-hospital transfers

       Critical Care Networks should consider the provision of appropriately equipped
        ambulances to facilitate the transport of critically ill patients. These should be
        designed with attention to the needs of both patients and staff

       Each critical care area should have access to a dedicated, suitably equipped transport
        trolley compatible with local ambulance mounting systems

       Appropriate transport equipment including monitors, ventilators and syringe pumps
        must be available. Ideally all equipment across a Critical Care Network should be
        standardised to enable the seamless transfer of patients between hospitals without
        interruption of drug therapy or monitoring

       Critically ill patients should be accompanied by at least 2 suitably experiences
        attendants, one of which should be a medical practitioner with appropriate training in
        intensive care medicine, anaesthesia or other acute speciality

       The decision to transfer a patient to another hospital is always a balance of associated
        benefits and risks, and must be made by a consultant in intensive care in discussion
        with consultant colleagues from the referring and receiving units. The final decision to
        accept a patient lies with the ICU consultant in the receiving unit

       When transfer is required for capacity reasons, guidelines on which patient to transfer
        have been previously published by the Department of Health

       The most appropriate mode of transport will be influenced by factors such as urgency,
        distance, weather conditions and availability. Transport by road is easier, cheaper and
        more familiar to staff. Helicopters should be considered for longer journeys or where
        road access is difficult. Fixed wing aircraft should be considered for journeys over 150
        miles



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       Patients should be meticulously resuscitated and stabilised prior to transfer. Patients
        with penetrating trauma or acute ruptured aortic aneurysm may be exceptions

       The minimum standards for monitoring during transport include continuous presence
        of appropriately trained staff, ECG, non invasive blood pressure, oxygen saturation,
        end tidal carbon dioxide and temperature. Invasive blood pressure measurement
        through an indwelling arterial cannula should be used in most cases

       In mechanically ventilated patients, the oxygen supply, inspired oxygen concentration,
        ventilator settings and airway pressure should also be monitored

       Safety is paramount. The patient should be secured in the trolley by means of a
        harness, and all equipment fastened to the trolley or securely stowed in lockers.
        Unnecessary high speed transfers should be avoided. Staff should remain seated at all
        times

       Transport of patients by air presents attendant staff with many problems relating to the
        unfamiliar environment, noise, vibration, poor access and visibility, and the effects of
        altitude. Staff should not undertake aero medical transport without appropriate training

       On arrival at the receiving unit there should be verbal and written handover to the
        receiving medical and nursing team

       Clear notes must be maintained at all stages. Standard transport documentation should
        be developed for use across Critical Care Networks

       Critical Care Networks should develop comprehensive quality assurance programmes
        including audit and critical incident reporting. The clinician in each hospital
        responsible for the organisation of hospital transport teams should ensure that all
        patient movements within the hospital are subject to similar scrutiny

       All individuals involved in the transport of critically ill patients should be suitably
        trained and experienced. Competency based training and assessment should be
        developed

       Despite precautions there is always the possibility of an ambulance being involved in
        an accident. The insurance situation in these circumstances is complex and staff should
        ensure they have appropriate insurance cover




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