Kent and Medway Stroke Review Dartford and Gravesham NHS Trust - - PowerPoint PPT Presentation
Appendix Wiv Kent and Medway Stroke Review Dartford and Gravesham NHS Trust Deliverability Panel 1 Contents Background and context Overview of the options How we will deliver the capacity How we will implement the model
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Please note - the following are indicated throughout the presentation against the
relevant icons:
Identified risks (also provided in Appendix A) Examples of our track record Quotes from relevant stakeholders
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Stoke services across the region have been challenged,
3 Dartford and Gravesham performance
stroke services across the Kent and Medway region have been inconsistent, leading to this review
region, Dartford and Gravesham has faced challenges, particularly during the review 2013/14 2014/15 2015/16 2016/17 2017/18
Scanning key indicators
Percentage of patients scanned within 1 hour
DGT 42.7% 51.4% 50.3% 53.0% 49.7% National
41.9% 44.1% 47.5% 51.3% 52.6%
Stroke Unit key indicators
Percentage of patients directly admitted to a stroke unit within 4 hours of clock start DGT 33.1% 59.2% 41.2% 30.1% 27.1% National
58.0% 56.8% 58.3% 57.4% 57.2%
Percentage of patients who spent at least 90%
DGT 79.7% 88.7% 84.0% 67.2% 66.3% National
83.0% 81.9% 83.5% 83.8% 76.2%
Thrombolysis key indicators
Percentage of eligible patients (according to the RCP guideline minimum threshold) given thrombolysis DGT 91.7% 95.2% 82.6% 92.3% 100.0% National
74.3% 80.7% 84.9% 86.9% 87.8%
Percentage of patients who were thrombolysed within 1 hour of clock start DGT 30.3% 45.2% 42.1% 76.0% 59.8% National
53.2% 56.1% 58.5% 62.3% 63.7%
“Joint assessment at the front door by the stroke
team and A&E colleagues is vital to ensure that patients
are triaged to receive the
right treatment, first time.”
Director, PRUH
Dartford and Gravesham has a clear action plan, a track record of
Example elements of the Dartford and Gravesham action plan:
within 60 minutes
bed
team, rehabilitation sites to ensure good patient flow
Track record of delivering improvements Track record: creating a ring-fenced bed
Results of introduction of ONE ring fenced bed in April 2018 to ensure the prompt transfer to the acute stroke unit. : Our direct admissions (total) has improved from all time low of 28% in Feb 2018 to 78% (April- July 2018)
Track record: driving up thrombolysis
An improvement project with a focused approach analysing door to needle SSNAP data to increase the percentage of patients thrombolysed (where thrombolysis is indicated) within 1 hour (golden hour); this project has been successful and sustained (evidenced in an increase in the percentage of patients thrombolysed within 1 hour from 30% in 2013/14 to 64% in 2-17/18)
Track record: an experienced team
Clinical lead for stroke: DGT’s dedicated and driven service lead is an experienced
stroke consultant who has developed the DGT stroke service and led on DGT’s service improvements, examples of which are outlined above Head of Nursing: DGT’s HoN was a stroke CNS and then a lead stroke nurse, providing clinical leadership and service development across Kent and Medway. She was a member of the expert clinical review group at the request of the South East Clinical Senate in 2016, and was previously member of the CRG for the K&M stroke review. General Manager: The DGT GM has previously supported delivery of two network stroke service solutions, one in Cambridge/ Peterborough and another in West Essex. 4
Key risk: Payment of best
practice tariff would still result in stroke being a loss- making service for the Trust. Both London and Manchester have implemented top-up rates for providers and we would wish to explore this further across Kent and Medway with our CCG commissioners.
Wider context to the provision of stroke services across Kent and
partner organisations, including rehabilitation service providers
–
Rehabilitation pathways and services are consistent across Kent and Medway
–
All Kent and Medway HASU/ASU staff have the same competencies and training
–
Patients from Bexley also follow the same standardised pathways, with efficient routes out to rehabilitation services
–
Standardisation is clinician-led across the region
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Track record of collaboration: Vanguard with Guy’s and St Thomas’: Through their Vanguard, Dartford and
Gravesham and Guy’s and St Thomas’ effectively collaborated in three clinical programmes in paediatric services, cardiology and vascular services. Over 1,100 patient appointments were held at DGT rather than GSTT over the 18 month period of the programmes, improving the experience of these patients by providing care closer to home and saving money within the local economy. The clinical programmes also supported the upskilling of DGT staff, and there is qualitative evidence that this has improved recruitment and retention
Key risk: The stroke service consultation does not include rehabilitation services; this poses a risk to patient flow from future HASU/ASUs. This needs to include the pathways into neuro rehab and nursing home beds. A lack of collaboration with the following partners would lead to difficulties in patient flow from DGT’s HASU/ASU and/ or ED: Bexley CCG, Virgin Healthcare, non-HASU/ASU DGHs
There are three options under consultation in which Dartford
6 Current number of beds at DVH
Under options
Number of
strokes TIAs Mimics HASU beds ASU beds Total beds
Bed increase
Options Option A:
Darent Valley Hospital Medway Maritime Hospital William Harvey Hospital 27 882 88 220 10 27 37 +10 Option B: Darent Valley Hospital Maidstone General Hospital William Harvey Hospital 27 807 81 202 10 24 34 +7 Option E: Darent Valley Hospital Tunbridge Wells Hospital William Harvey Hospital 27 1,174 117 293 14 36 50 +23
Options A and B are comparable in scale for DVH; deliverability is considered broadly equal Option E is considerably larger for DVH; deliverability challenges scale up for this option
The deliverability of the HASU/ASU will be dependent on
7 Capacity constraint
High-level view
Page ref.
Medical beds Capacity in medical beds across the organisation options A, B and E; in all cases sufficient capacity
Please note that the implementation plans are
provided on pages 16-20. The capacity of DVH has been modelled under can be achieved. Please note that
interdependencies are further details on p. 21
8 Capacity within A&E, resus and ITU The increase in stroke service activity under
and resus, and may impact ITU. The existing capacity constraint within the A&E department will be eased through the co
ambulatory pathways. Additional resus capacity is planned, and ITU is expected to be able to absorb any small activity increase. 9 Radiology capacity The HASU/ASU will require radiology capacity for urgent patients. Existing on-site machines have sufficient capacity for all A&E, in-patient and future stroke patients. 10 Workforce A gap analysis has been completed to indicate the increase in workforce required under each
resource is also considered. Radiology clinical workforce remains a key risk for all units across the region. Mitigations (workforce engagement, planning) have been completed, although greater mitigation will be possible once the option decision is taken. 11-15
population growth (including Ebbsfleet), include the impact
the impact of Local Care, which is planned to reduce length of stay and avoid admissions in the medium-long term (see p. 18)
the site plan (see Appendix B) to ensure sufficient capacity 8 Modelled impact on medical bed capacity under a 92% occupancy rate
Key risk: The Local
Care initiative may be unsuccessful in reducing average length of stay. This risk is to be mitigated by the appointment
Programme Manager between DGT and the CCG
Track record of delivering a LOS reduction: The average adult medicine non-elective length of stay at DGT has reduced from 6.86 days (2016/17) to 5.48 (2017/18). A reduced length of stay is
known to reduce infection rates and improve overall patient outcomes as well as patient
Current number of beds 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27
Option A
Stroke adjustments
10 10 11 11 11 11 Beds needed 435 449 452 474 492 508 523 537 556 574 Shortfall of beds
Option B
Stroke adjustments
7 7 7 8 8 8 Beds needed 435 449 452 471 489 505 520 534 553 571 Shortfall of beds
Option E
Stroke adjustments
23 24 24 25 25 25 Beds needed 435 449 454 487 505 522 537 551 570 589 Shortfall of beds
Key risk: The DGT A&E department, as with other Trusts across the region, is at present stretched, with 88.6% of all attendees seen within 4 hours in July
through the various improvement workstreams and the planned co- location of UTC services within Darent Valley Hospital.
Track record delivering increased A&E
activity: South East London closed its A&E and maternity units at Queen Mary Hospital in 2010. DVH became the primary provider for the population of Bexley and the surrounding areas. A&E 4-hour targets remained stable
Healthcare Trust was dissolved; DGT took on numerous elective services for Bexley and the surrounding areas. Zero patients were lost, harmed or inconvenienced through the transfer, evidencing a track record of well managed, large scale transformation.
A&E
Resus
ITU
at Gravesend Hospital, walk in centre at Northfleet, and GP out-of-hours services) will all be co-located at Darent Valley Hospital with the A&E department
leaving A&E capacity for emergency patients including for HASU/ ASU
Rapid Assessment and Treatment, etc.)
support options A and B; this can fit without difficulty into the existing resus unit
population increase and any increase from a model change
Learning from the London implementation suggests that capacity is needed to support patients who have been in ITU and who require tracheostomy management within the stroke ward, as opposed to within a respiratory pathway. This will require the upskilling of nurses (see p. 12). 9
Radiology capacity is not considered to be a risk given DGT’s
– – –
–
Two CT at Darent Valley Hospital One CT at Queen Mary Sidcup One MRI at Darent Valley Hospital Additional MRI capacity is available through Alliance Medical at Queen Mary Sidcup
unused sessions within a 9am-5pm working week, and is not used during evenings; additional elective activity currently completed at DVH could therefore be moved to Queen Mary Sidcup
ambulatory patients, there is no anticipated risk regarding
expected additional CT and MRI activity from both population growth and the implementation of a HASU/ASU under options A, B and E
including a radiographer, stroke nurse and stroke consultant, in order to access CT/ CT angiograms, would be beneficial
Key risk: Should one of the two on-site scanners break, this could cerate a risk by which the Trust has one scanner to meet the needs of A&E and the HASU/ASU. However, given the investment into a new machine for September 2018 and the presence of two on-site machines, the risk to patients is perceived to be low.
Track record: Working with partners to drive innovation
Through the Healthcare Alliance, DGT is working with Guy’s and St Thomas’ to drive innovation in radiology reporting. This workstream aims to release overall capacity in the system through standardisation and by enabling remote reporting at each Trust. This collaboration is an example of DGT actively looking for areas of future capacity constraint to pro-actively manage them.
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A gap analysis has been completed of the workforce
Key risk: The gap analysis shows a large gap in typically difficult-to-recruit groups, which poses a material risk.
Staff group
In post 30th
April 2018
Required for
HASU/ASU
Gap
TUPE from
Revised Gap
Option A
Consultant 1.00 7.10 6.10 1.12 4.98 Nurses (reg. and unreg.) 32.80 66.01 33.21 6.84 26.38 Scientific, Therapeutic & Technical 8.30 20.05 11.75 4.37 7.38 Stroke co-ordinators, healthcare assistants and administration
7.00
Option B
Consultant 1.00 7.10 6.10 1.48 4.62 Nurses (reg. and unreg.) 32.80 61.40 28.60 7.06 21.54 Scientific, Therapeutic & Technical 8.30 18.42 10.12 4.79 5.33 Stroke co-ordinators, healthcare assistants and administration
7.00
Option E
Consultant 1.00 7.10 6.10 1.39 4.71 Nurses (reg. and unreg.) 32.80 87.87 55.07 6.68 48.38 Scientific, Therapeutic & Technical 8.30 26.36 18.06 5.86 12.20 Stroke co-ordinators, healthcare assistants and administration
7.00
Assuming a TUPE of 6.68 WTE nurses from closing units, option E would require the recruitment of 48.38 WTE nurses, of which 38.02 are registered Options A and B require significant recruitment. For option E the level of recruitment is further scaled up, which poses a proportionally higher risk. In addition, the movement to a full 7-day supporting radiology service will require additional requirement 11
Key risk: Further work needs to be undertaken to ensure that sufficient non-patient contact time has been included for all staff groups.
A recruitment and training plan is set out to meet the needs of a
Trusts
–
Recruitment will be through multiple routes, including staff from closing stroke units within the region, staff from outside the region, and newly-qualified staff
–
In particular, DGT has established strategies for local, national and international nurse recruitment
–
DGT will also work with partners in London, as it does with GSTT through the Healthcare Alliance, to offer an attractive career progression model to retain staff within the NHS
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DGT has existing strong relationships with local universities providing newly-qualified staff
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HASU/ASU training, including tracheostomy management, will be provided by current medical, nursing and therapy specialists; DGT benefits from the presence of a Caroline Bates, the Head of Nursing for Emergency and Adult Medicine, who has significant experience as a specialist within stroke
–
Learning from the London implementation would suggest a key role for a pathway coordinator, at least weekly education meetings, and links to a nurse consultant could be of significant benefit across the network
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DGT will support the development of the stroke clinical network with shared regional competencies
–
DGT will also look to access expertise from the South East London Cardiovascular network
Key risk: The proposed staff numbers are subject to sensitivity analysis; there is a risk that under a more conservative model the numbers could increase. This poses a particular risk under
Track record of innovative workforce design: Doctor Assistants
Support doctors with admin tasks, reducing doctor time spent on administration and resulting in more time spent on patient care. They have also improved consistency with medical notes, and help to coordinate the process of completing electronic discharge notifications
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Activity
Decision
09/18 10/18 11/18 12/18 1/19 2/19 3/19 4/19 5/19 6/19 7/19 8/19 9/19 10/19 11/19 12/19
Recruitment
Engage staff at closing units Engage universities Recruitment drive
Training
Standardisation of competencies Training of stroke staff to competencies Specialist training
Leadership
Set the Executive SRO
Procure project management resource Leadership improvement skills training
Staff, public and patient engagement Go/ no-go review for safe handover Post-transfer review process
These activities will run in parallel to the implementation programme, as outlined on p. 17 and within Appendix D 13
All DGT staff have been engaged throughout the consultation
Examples of staff engagement through the consultation process
Healthwatch has been shared with all staff
Reference Group
which representatives from all therapist groups have attended
attendance at the STP stroke consultation workforce group
the rehabilitation workstream throughout the consultation
the monthly stroke meetings
discuss the consultation
workshops being held by the STP on the consultation
Key risk: Throughout the consultation there is a risk that stroke staff are lost across the system to other regions or services due to uncertainty. This is being mitigated through workforce engagement.
Key risk: In setting up the HASU/ASU, DGT will be looking to recruit staff from closing stroke services. However, this will rely on ensuring an attractive offer (for example, through leveraging the Healthcare Alliance relationship with Guy’s and St Thomas’ for leadership development and
double running could present a situation in which new units must open before the closure of existing.
“When the Senior Physiotherapist does attend meetings regarding the service, she is very good in relaying the information back to her staff. I understand why services are being re-designed, and am reassured that each staff member
is going beyond their way in caring for patients.”
Band 6 rotational physiotherapist, DGT
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Senior Responsible Officer
Clinical Director
Epsom St Helier during its implementation.
Project Management
HASU/ASU delivery. This will also draw on the expertise of GSTT through the Healthcare Alliance. Key risk: The Local Care initiative may be unsuccessful in reducing average length of stay, which would pose a risk that the modular unit would not be removed within three years as planned (see p. 18). This risk is to be mitigated by the appointment of a joint Local Cate Programme Manager between DGT and the CCG.
Track record of delivering a major project:
A&E redesign: Maintaining a safe service during a major
extension to the emergency department, providing essential capacity to the emergency workstream through a c. £4m investment GP streaming: ED maintained operational while reconfiguring entrance to implement two new GP rooms
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16
Implementation consideration High-level view
Page ref.
Timeline/ implementation plan
and go-live date
DM Business Case / Selection –
Trust Business approved - Planning approval - Funding available - Works Complete, HASU open 13 19
th Sept 2018
Dec 2018 Feb 2019 Apr 2019 Dec 2019
th
28 08
th th
13
th
17 Architectural drawings Please note that detailed
drawings are provided within
Appendix B Plans to accommodate the beds for the 3 options for DVH have been developed and are included in Appendix B. Further detailed design will be undertaken on the preferred option. 18
Capital requirements
At PCBC a capital requirement was estimated for DGT based on initial scoping of the three options. Since this stage, further development of the plans has demonstrated that Options A and B remain within this estimated capital requirement, whereas Option E is now above the PCBC estimate. 19 Key mobilisation activities
(including planning permission)
Risks associated with key mobilisation activities are being, or will be as appropriate, actively managed to ensure successful delivery. 20
17
Key risk: Only two months of double running have been budgeted for; this suggests a need for units to
go-live date, but is adjustable to mitigate this risk.
Appendix D provides further detail regarding the implementation programme; for more information regarding the recruitment and training plan, see p. 13
Activity
Decision
09/18 10/18 11/18 12/18 1/19 2/19 3/19 4/19 5/19 6/19 7/19 8/19 9/19 10/19 11/19 12/19
DM Business Case (Selection and approvals) Trust Full Business case (Equivalent)
Ward costing Modular Unit costing FBC (equivalent)
Local Authority Planning Works (Sequential, Modular and Internal)
Modular Unit works Ward works
Commission DVH HASU / ASU
18
development of an existing ward (adjacent to the current stroke unit). Space has been allocated, both to a TIA clinic area and to a TIA assessment area following learning from the London implementation.
activity planning (see p. 8). During these three years the Local Care initiative will reduce admissions and the average length of stay; DGT’s track record in reducing length of stay is also described on p. 8.
which are provided within Appendix B. These plans are well advanced, ensuring that mobilisation activities can be completed pro-actively with the timeline remaining flexible to minimise double-running (see p. 17).
Track record of delivering: Heart Centre
The Trust has undertaken major new builds on the site. The Heart Centre was commissioned and build on the site. The Heart Centre was built on the Hospital site, attached to the building.
Track record of delivering: Internal beds
A c. £2.5m investment was made over two years to remove non-clinical functions from inside the ward environment, creating 25 additional beds. This involved reconfiguring wards whilst maintaining the safe operation of normal clinical services. Key risk: Option E does not provide further room for future growth within the existing space and no flexibility within the model. Any growth would require a new build.
Options A and B remain in line with the PCBC DGT
19
this estimated capital requirement, whereas Option E is now above the PCBC estimate Key risk: The capital envelope was set at PCBC stage. However, the plans will be further developed as part
and optimism bias has been factored into the capital cost in order to mitigate this risk.
Capital requirement (£ ‘000s)
Option A Option B Option E Item Works subtotal (beds and resus bay requirements) 314 241 1,137 Fees 79 60 284 Equipment costs 47 36 171 Non-works 5 4 17 Planning contingency 45 34 161 Optimism Bias 127 97 458 VAT 107 83 389
Total
723 556 2,617
20 Key mobilisation activity Perceived risk
Mitigation
Establishing planning permission Planning delayed due to limitation
car parking at the hospital site Trust met Planning Authority and progressing presentation to the Development Committee and preparing car park expansion proposals for submission to the Local Authority Discharging planning conditions Delay in discharging Planning conditions Estates Capital lead has met Local Planning leads and will maintain dialogue to communicate the Stroke proposal and benefit to the Dartford Community Procurement of modular unit Delay in design and delivery of the Modular Unit Initial meeting progressed with supplier. Early design and procurement planned if selected as preferred option Conclusion of the contract Delay in signing-off PFI Contract variation document documentation Trust informed PFI Partner of Stroke
Hospital site to the PFI Hospital Directors
There are a number of interdependencies which will materially
21
Interdependency Management approach
External
stakeholders Patient pathways into
rehabilitation
HASU/ASU will be the pathway into rehabilitation
partner organisations, including in co-designing patient pathways CCGs Virgin Care Patient pathways for
patients identified as non-
stroke
pathway for patients presenting at a HASU/ASU who are determined to be non-stroke Non-HASU/ASU DGHs
Local Care implementation
be delivered through the Local Care initiative; this will allow for the removal of the modular unit within three years
CCGs Primary and community care
System-wide workforce
requirements
aligned recruitment strategies and a shared competency framework
All NHS Trusts
System-wide public
engagement
highest number of responses from the public to the consultation
1
effectively, the public across the region must be engaged with a consistent
message and in a pro-active way All organisations
Source: 1. Stroke CRG May 2018 minutes
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Gerard Sammon Interim Chief Executive
“We are committed to working hard to see these changes implemented in the most effective way over the next
couple of years and would do everything we could to get the new service up and running as quickly as possible. We can act quickly because our service model is based on immediate refurbishment, which also provides a cost effective
solution.” Peter Coles Chairman
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Risk
Mitigation
Page ref.
The stroke service consultation does not include rehabilitation services; this poses a risk to patient flow from future HASU/ASUs. A lack of collaboration with the following partners would lead to difficulties in patient flow from DGT’s HASU/ASU and/ or ED: Bexley CCG, Virgin Healthcare, non-HASU/ASU DGHs
region
5 The Local Care initiative may be unsuccessful in reducing average length of stay.
Braysher as joint lead between DGT and the CCG 8 The DGT A&E department, as with other Trusts across the region, is at present stretched, achieving 88.6% of all patients seen in less than 4 hours in July 2018.
9 Should one of the two on-site CT scanners break, this could create a risk by which the Trust has one CT scanner to meet the needs of A&E and the HASU/ASU.
scanner for September 2018 and the presence of two
10 The gap analysis shows a large gap in typically difficult-to-recruit groups, which poses a material risk.
A recruitment and training plan, outlined on p. 12-13 Engagement of the existing workforce, outlined on p. 14 11 The proposed staff numbers are subject to sensitivity analysis; there is a risk that under a more conservative model the numbers could increase. This poses a particular • risk under option E. As above 12 Throughout the consultation there is a risk that stroke staff are lost across the system • to other regions or services due to uncertainty. This risk is mitigated through engagement of the existing workforce 14 In setting up the HASU/ASU, DGT will be looking to recruit staff from closing stroke
limited planning period of double running could present a situation in which new units must open before the closure of existing.
14 The Local Care initiative may be unsuccessful in reducing average length of stay, which would pose a risk that the modular unit would not be removed within three years as planned.
Braysher as joint lead between DGT and the CCG. 15
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Risk
Mitigation
Page ref.
Only two months of double running have been budgeted for; this suggests a need for • units to open/close within a tight time scale. The programme timeline and plan is adjustable to mitigate this risk. 17 Option E does not provide further room for future growth within the existing space and no flexibility within the model. Any growth would require a new build.
18 The capital envelope was set at PCBC stage. However, the plans will be further developed •
as part of the full business case completion. Contingency and optimism bias has been factored into the capital cost in order to mitigate this risk.
19
Planning delayed due to limitation on permissible development and car parking at the hospital site
presentation to the Development Committee and
preparing car park expansion proposals for submission to
the Local Authority 20
Delay in discharging Planning conditions
maintain dialogue to communicate the Stroke proposal and benefit to the Dartford Community 20 Delay in design and delivery of the Modular Unit
procurement planned if selected as preferred option 20 Delay in signing-off PFI Contract documentation
to accommodate Stroke in Hospital site to the PFI Hospital Directors 20
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Appendix Description
Appendix B Stroke
Ward Estates Plan
Architects drawings for medical beds:
Page 1: Modular unit for three years of additional capacity
Page 2: Option A HASU/ASU layout Page 3: Option B HASU/ASU layout Page 4: Option E HASU/ASU layout
Appendix C Stroke
Resus proposal Architects drawing for one additional resus bed within the existing department, in line with Option A and Option B.
Please note: Option E requires two additional resus beds. Whilst a drawing of this has not been commissioned at this time, the architect has stated that this will be possible within the existing unit using a similar design at the other end of the unit.
Appendix D Detailed
programme Gantt chart
Detailed programme Gantt site implementation) chart for the implementation of the HASU/ASU (physical