Urgent & Emergency Care and Ele lective Ort rthopaedic - - PowerPoint PPT Presentation

CONFIDENTIAL

Assessing options against hurdle cri riteria Urgent & Emergency Care and Ele lective Ort rthopaedic Services

November 2017

Establishing the medium list of options

1

CONFIDENTIAL

Urgent care services Background

Con

• ntents

Appendix Applying the hurdle criteria on urgent care options Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Single site developer options at K&CH Agreed K&M Fixed Point Criteria

2

CONFIDENTIAL

A num number r of

• f ser

servic ices in n Eas ast Ken ent req equir ire ur urgent t con

• nsoli

lidatio ion to

• impr

prove qua quali lity ty

Stroke Vascular Acute medicine and ED Paediatrics 2C Deliverability 1A Clinical case inc workforce 2A Work done to date 2B Wider readiness of public and stakeholders 1B Requirements to consult* Smaller specialist services Cancer Community beds Maternity Diagnostics Outpatients Wider elective surgery EK WK Elective orthopaedics

Prioritised services Very high High Medium Low

Prioritised Services for phase 1 consultation

3

CONFIDENTIAL

Stroke Vascular

• There are two hospitals in K&M that provide emergency vascular services and

neither meet the majority of the national guidelines.

• There is no 24/7 access to specialist vascular care
• There is an agreed network strategy across East Kent Hospitals University NHS

Foundation Trust (EKHUFT) and Medway Maritime Foundation Trust (MMFT)

• It has been agreed that a single

vascular service will be delivered across K&M with a arterial centre on

• ne site
• National guidelines state that specialist doctors, nurses and therapists should

be available 24/7; none of the hospitals in east Kent achieve this.

• No hospital in east Kent thrombolyses all eligible stroke patients within the

national guideline recommended time of 60 minutes.

• Urgent need to consolidate services

to improve quality and reduce likelihood of excess mortality. Service Case for Change Implications

Cas ase for

• r Cha

hange of

• f the

the pri priorit itis ised ser servic ices for

• r Pha

hase 1 Con

• nsultatio

ion in n ea east Ken ent

SOURCE: Kent & Medway Case for Change, Carnall Farrar analysis

• Significant opportunities to improve

efficiency and quality by standardising planned care to best practice by consolidating elective inpatient orthopaedics. Elective Orthopaedics

• A rise in the elderly and obese population is driving an increase in demand
• Waiting lists for planned care are growing
• Pressure from emergency patients requiring admission is increasing the

number of on the day cancellations.

• Patient experience and outcomes could be improved
• Workforce constraints prevent the delivery of 7 day services and 24/7

consultant cover across most hospitals in east Kent.

• In some hospitals, senior doctors are not present at the weekend or are trying

to cover more than one clinical area at a time.

• Support services for discharge are also not available at the weekend.
• The configuration of acute medicine

sites should be optimised according to Keogh definitions to deliver more senior doctor cover.

• Across Kent & Medway (K&M), attendances to major ED departments have

risen by 2.2% per year over the last 3 years (twice the national average)

• Providers have some of the worst patient satisfaction scores in the country for

ED

• Performance on the 4 hour waiting target has deteriorated over the last 2
• years. On average 86% of people in K&M are discharged within 4 hours (target

= 95%).

• The configuration of acute medicine

sites should be optimised according to Keogh definitions. Acute medicine Emergency Departments Urgent care b a

4

CONFIDENTIAL

Urgent care services Background

Con

• ntents

Appendix Applying the hurdle criteria on urgent care options Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Single site developer options at K&CH Agreed K&M Fixed Point Criteria

5

CONFIDENTIAL

K& K&M Fix Fixed Poin

• ints Crit

riteria ia

• Kings College Hospital London is the designated major trauma centre;
• Private Finance Initiative (PFI) as follows:
• Dartford;
• Pembury;
• Gravesend,
• Westbrook House & West View; and
• 12 Care Homes built under a PFI arrangement for Kent County Council (KCC)
• 4 Healthy Living Centres in Medway built under LIFT
• Current road network – no plans are in place to create a new road network which would

impact travel times by 20/21. This means travel times will not change as a result of new built major roads before 20/21.

The following fixed points criteria were agreed across K&M for all reconfigurations:

6

CONFIDENTIAL

Urgent care services Background

Con

• ntents

Appendix Applying the hurdle criteria on urgent care options Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Single site developer options at K&CH Agreed K&M Fixed Point Criteria

7

CONFIDENTIAL

Develo lopin ing the the op

• ptio

ions for

• r ser

servic ices acr across ea east Ken ent

WHH K&C QEQM

In east Kent, there is one trust (east Kent Hospitals Foundation Trust - EKHUFT) providing services across three main acute sites (William Harvey Hospital - WHH, Queen Elizabeth the Queen Mother Hospital - QEQM and Kent and Canterbury Hospital - K&C),

• ffering many similar services.

Each service could be provided

• n:
• 3 sites
• 2 sites
• 1 site
• 0 sites

Applying the hurdle criteria to assess the options for the identified services will result in a short list of potential viable

• ptions for evaluation in further

detail.

8

CONFIDENTIAL

Our Services K&C WHH QEQMH Clinical Support Services Interventional radiology ✓ ✓ ✓ Outpatient and diagnostic services ✓ ✓ ✓ Therapy services ✓ ✓ ✓ Inpatient rehabilitation ✓ ✓ ✓ Specialist Services Cancer care (chemotherapy) ✓ ✓ ✓ Cancer care (radiotherapy) ✓ Child ambulatory services ✓ ✓ ✓ Community child health services ✓ Haemophilia services (O/P) ✓ Inpatient child health services ✓ ✓ Inpatient clinical haematology ✓ Dermatology ✓ Inpatient renal services ✓ Renal dialysis ✓ ✓ ✓ Our Services K&C WHH QEQMH Specialist Services cont…. Inpatient obstetrics, gynaecology and consultant-led maternity ✓ ✓ Midwifery-led birthing units ✓ ✓ Neo-natal intensive care unit ✓ Special care baby unit ✓ ✓ Surgical Services Critical Care Intensive Therapy Unit (ITU) / High Dependency Unit (HDU) ✓ ✓ ✓ Day case surgery ✓ ✓ ✓ Inpatient acute coronary care services ✓ ✓ ✓ Inpatient breast surgery ✓ ✓ Inpatient emergency general surgery ✓ ✓ Inpatient emergency trauma services ✓ ✓ Our Services K&C WHH QEQMH Surgical Services cont…. Inpatient ENT (ear, nose and throat),

• phthalmology and
• ral surgery

✓ Inpatient maxillofacial ✓ Inpatient

• rthopaedic

services ✓ ✓ Inpatient urology services ✓ Inpatient vascular services ✓ Orthopaedic rehabilitation ✓ ✓ Urgent Care & LTC Services 24-hour GP led Urgent care centre ✓ Accident and emergency ✓ ✓ Minor injuries unit ✓ ✓ ✓ Inpatient emerg. medicine *✓ ✓ ✓ Acute elderly care services ✓ ✓ ✓ Acute stroke ✓ ✓ ✓ Our Services K&C WHH QEQMH Urgent Care & LTC Services cont… Diagnostic and interventional cardiac services ✓ ✓ Endoscopy services ✓ ✓ ✓ Inpatient cardiology ✓ ✓ ✓ Inpatient diabetes service ✓ ✓ ✓ Inpatient gastroenterology services ✓ ✓ ✓ Inpatient neurology ✓ ✓ ✓

Inpatient neurorehabilitation

✓ Inpatient respiratory ✓ ✓ ✓ Inpatient rheumatology ✓ ✓ ✓ Neurophysiology services ✓ Ortho-geriatric services ✓ ✓

EKHUFT has a broad range of services across three sites

Source: EKHUFT 2015/16 annual report * Service has temporarily moved

9

CONFIDENTIAL

Urgent care services Background

Con

• ntents

Appendix Applying the hurdle criteria on urgent care options Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Single site developer options at K&CH Agreed K&M Fixed Point Criteria

10

CONFIDENTIAL

A set t of

• f hurdle crit

criteria ia have e bee een agr greed by th the e Clin Clinical l Boa Board and Fin inance e wor

• rking Group

Is the potential configuration option clinically sustainable?

• Does it deliver key quality standards?
• Does it address any co-dependencies?
• Will the workforce be available to deliver it?
• Will there be sufficient throughput or catchment population to maintain skills and deliver

services cost effective? Is the potential configuration option financially sustainable?

• Must not increase the ‘do nothing’ financial baseline

Is the potential configuration option implementable?

• Will the option deliver financial and clinical sustainability within a medium-term

timeframe by 20/21? This statement is based upon a system wide view, this may mean that some organisations have a net negative financial impact as well as some have a net positive impact.

• Does it implement the outcome of other recent consultations or designation processes?

Is the potential configuration option a strategic fit? Is the potential configuration option accessible?

• Is the maximum travel time (by car) an average of one hour or less?

11

CONFIDENTIAL

Th The e Keo eogh rep eport rt (2 (2014) ) se sets ou

• ut

t a a mod

• del

l for

• r dif

different t ty type pes of

• f cen

centres tha that can pr provid ide ur urgent t and and em emer ergency care

Major Emergency Centre with specialist services Emergency Centre Medical Emergency Centre Urgent care centre* Integrated care hub with emergency care* Major trauma centre What Services offered

• Larger units, capable of assessing and initiating

treatment for all patients and providing a range of specialist hyper-acute services

• Serving population of ~ 1-1.5m
• Hyper-acute cardiac, stroke , vascular services
• Trauma unit
• Level 3 ICU
• Moving towards 24x7 consultant delivered A&E, emergency

surgery, acute medicine, inpatient paediatrics

• Full obstetrics and level 3 NICU
• Larger units, capable of assessing and initiating

treatment for the overwhelming majority of patients but without all hyper-acute services

• Serving population of ~ 500-700K
• Moving towards 24x7 consultant delivered A&E,

emergency surgery, acute medicine

• Level 3 ICU
• Inpatient paediatrics and obstetrics with level 2/3 NICU
• Assessing and initiating treatment for majority of

patients

• Acute medical inpatient care with intensive

care/HDU back up

• Serving population of ~ 250-300K
• Consultant led A&E
• Acute medicine and critical care/HDU
• Access to surgical opinion via network
• Possibly paediatrics assessment unit and possibly

midwife-led obstetrics

• Immediate urgent care
• Integrated outpatient, primary, community and

social care hub

• Serving population of ~ 50-100K
• As above but no beds
• Assessing and initiating treatment for large

proportion of patients

• Integrated outpatient, primary, community and

social care hub

• Serving population of ~ 100-250K
• GP-led urgent care incorporating out of hours GP services
• Step up/step down beds possibly with 48 hour

assessment unit

• Outpatients and diagnostics
• Possibly midwife-led obstetrics
• Specialised centres co-locating tertiary/complex

services on a 24x7 basis

• Serving population of at least 2 -3million
• Neurosurgery, Cardiothoracic surgery
• Full range of emergency surgery and acute medicine
• Full range of support services, ITU etc

Source: Sir Bruce Keogh, Transforming Urgent and Emergency care services in England, End of Phase 1 Report, 2014 * Detailed specification being prepared by Local Care workstream

12

CONFIDENTIAL

Th The e thr three ty type pes of

• f Em

Emer ergency ce centr tre laid id out

• ut in

n the the Keo eogh rep eport rt ar are sub subsets of

• f ea

each

• t
• ther:

r: All ll MECs ar are e al also a a EC and and an an Med edEC, al all l ECs ar are also also an an Med edEC

Medical Emergency Centre Emergency Centre Major Emergency Centre with specialist services

A MEC will have everything in an EC and MedEC, plus:

• Vascular services
• Trauma unit
• Level 3 Intensive Care Unit (ICU)
• Moving towards 24x7 consultant delivered A&E,

emergency surgery, acute medicine, inpatient paediatrics

• Full obstetrics and level 3 Neo-natal Intensive Care

Unit (NICU) An EC will have everything in an MedEC, plus:

• Moving towards 24x7 consultant delivered A&E,

emergency surgery, acute medicine

• Level 3 ICU
• Inpatient paediatrics and obstetrics with level 2/3

NICU A MedEC will have:

• Consultant led A&E
• Acute medicine and critical care/High

Dependency Unit (HDU)

• Access to surgical opinion via network
• Possibly paediatrics assessment unit and possibly

midwife-led obstetrics

Major Emergency Centre with specialist services Emergency Centre Medical Emergency Centre

13

CONFIDENTIAL

Non

• n-acute ur

urgent t car are op

• pti

tions – In Integrated Car are Hosp

• spital and

and/or r Urgen ent t Car are Cen entre

Integrated Care Hospital Urgent Care Centre

An ICH will have

• GP led urgent care 24/7
• Step up/down beds
• Out patients and diagnostics

An UCC will have

• As above but with no beds

Com

• mmis

issio ioners will ill wor

• rk tog
• gether to
• loo

look at t the these op

• ptio

ions an and the the evalu luatio ion cri criteria ia pa pack will ll pr prog

• gress the

them whe here app appli licable

14

CONFIDENTIAL

The The fol

• llo

lowin ing spe specif ific icatio ion for

• r a

a Majo ajor r Em Emer ergency Cen entr tre with spe specia iali list ser services has has bee been ag agreed bas based on

• n the

the Keo eogh mod

• del

l an and SEC Clin inic ical l Sen enate ser servic ice co-dependencies

Source: [The Clinical Co-Dependencies of Acute Hospital Services: A Clinical Senate Review December 2014], Carnall Farrar analysis

• In-reach may be sufficient depending on ED pathways (required for a trauma unit)

*Non-specialised paediatrics and paediatric surgery

Acute cardiology Urology* Urgent GI endoscopy Anaesthetics Vascular surgery (spoke) Interventional cardiology (PC/i) Vascular surgery (hub)

• HASU
• Interventional radiology

Hyper acute stroke unit Acute stroke unit Inpatient rehabilitation Respiratory medicine Medical gastroenterology Critical care (L1, L2 & 3) Trauma Acute gynaecology General surgery Liaison psychiatry Acute paediatrics* Trauma unit

• Acute paeds

Acute and general medicine (inc. AMU) ENT* Consultant-led obstetrics Emergency Department (unselected) Elderly medicine Orthopaedics* Diagnostics inc. MRI Urgent haematology Clinical microbiology Interventional radiology Support services (see key) Rheumatology Dermatology Nephrology (not including dialysis) Maxillo-facial surgery Neurology Palliative care Acute oncology Plastic surgery Burns

Key Additional services that should in-reach if not based on- site Co-location on same site Specialist services Support services

▪

Co-located

–

Social care

–

Physiotherapy

–

Occupational Therapy

–

Lab based diagnostics

–

Emergency imaging and reporting

▪

Ideally co-located

–

Speech and language therapy

–

Dietetics

Diabetes & endocrinology Ophthalmology

15

CONFIDENTIAL

Th The e fol

• llo

lowin ing spe specif ific icatio ion for

• r an

an Em Emer ergency Cen entre has has be been ag agreed bas based on

• n the

the Keo eogh mod

• del an

and SEC Clin linical l Sen enate ser service co-dependencie ies

Source: [The Clinical Co-Dependencies of Acute Hospital Services: A Clinical Senate Review December 2014], Carnall Farrar analysis

• In-reach may be sufficient depending on ED pathways (required for a trauma unit)

*Non-specialised paediatrics and paediatric surgery

Acute cardiology Urology* Urgent GI endoscopy Anaesthetics Vascular surgery (spoke) Interventional cardiology (PC/i) Vascular surgery (hub)

• HASU
• Interventional radiology

Hyper acute stroke unit Acute stroke unit

• Inpatient rehabilitation

Respiratory medicine Medical gastroenterology Critical care (L1, L2 & 3) Trauma Acute gynaecology General surgery Liaison psychiatry Acute paediatrics* Trauma unit

• Acute paeds

Acute and general medicine (inc. AMU) ENT* Consultant-led obstetrics Emergency Department (unselected) Elderly medicine Orthopaedics* Diagnostics inc. MRI Urgent haematology Clinical microbiology Interventional radiology Support services (see key) Rheumatology Dermatology Nephrology (not including dialysis) Maxillo-facial surgery Neurology Palliative care Acute oncology Plastic surgery Burns

Key Additional services that should in-reach if not based on- site Co-location on same site Networked Support services

▪

Co-located

–

Social care

–

Physiotherapy

–

Occupational Therapy

–

Lab based diagnostics

–

Emergency imaging and reporting

▪

Ideally co-located

–

Speech and language therapy

–

Dietetics

Diabetes & endocrinology Ophthalmology

16

CONFIDENTIAL

Source: [The Clinical Co-Dependencies of Acute Hospital Services: A Clinical Senate Review December 2014], Carnall Farrar analysis

Anaesthetics Urgent GI endoscopy Liaison psychiatry Respiratory medicine Medical gastroenterology Clinical microbiology General (adult) surgery Acute and general medicine (inc. AMU) Diagnostics inc. MRI Elderly medicine Critical Care (L2 &L3) Urgent haematology Acute cardiology Rheumatology Dermatology Nephrology (not including dialysis) Neurology Palliative care Acute oncology Urology Diabetes & endocrinology Support services (see key) Consultant-led obstetrics

• Neonatology

Urgent care centre Fracture clinic

Key Additional services that should in-reach if not based on- site Co-location on same site Could be co- located on site Support services

▪

Ideally co-located

–

Social care

–

Physiotherapy

–

Occupational Therapy

–

Lab based diagnostics

–

Emergency imaging and reporting

–

Speech and language therapy

–

Dietetics

Paediatric assessment unit Rehabilitation Dialysis Ophthalmology Maxillo-facial surgery Vascular surgery (spoke) Interventional radiology Emergency department (selective)

Th The e fol

• llo

lowin ing spe specif ific icatio ion for

• r an

an Med edic ical Em Emer ergency Cen entre has has be been ag agreed bas based on

• n

the the Keo eogh mode

• del

l and and SEC Clin inic ical l Sen enate ser servic ice co-dependencies

17

CONFIDENTIAL

K&C WHH QEQM

Site Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 Option 8 Option 9

MEC MEC EC EC

ICH Emergency centre UCC ICH Integrated care hospital Urgent care centre Major emergency centre with specialist services UCC ICH

MEC EC

UCC ICH

MEC EC EC

UCC ICH

MEC MEC EC

UCC ICH

Green field site

None – no centre GFS

MEC

Single site

• n existing

site Closing a site

UCC

MEC MEC

Lon

• ng list

t of

• f op
• ptio

ions for

• r ur

urgent car are ser servic ices

Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it

EC

MedEC MedEC MedEC MedEC MedEC MedEC

Medical Emergency Centre

18

CONFIDENTIAL

Ass ssessing the the impa pact of

• f hur

hurdle le crit criteri ria

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

19

CONFIDENTIAL

Ana naly lysis is of

• f cli

clinic ical l sus sustainabil ilit ity and and via viabil ilit ity has has focussed on

• n tw

two

• que

questio ions

Answering these two questions will enable an assessment of the number of sites from which urgent and emergency care services can be provided in east Kent Do the services deliver to standards, and is the workforce available to deliver it?

• There are a variety of quality standards that providers should meet which include staffing levels, access to

support services and timing of treatment.

• It is difficult for small services to meet quality standards, often because of the lack of sufficient workforce

and access to specialist equipment.

• There are minimum staffing requirements that need to be met by services to deliver quality standards and

meet policy initiatives such as 7-day working.

• There are shortages in some staff groups and staff cannot easily be recruited.

2 Is there sufficient catchment / throughput?

• Services must treat a large enough volume of patients for staff to retain their skills and for services to be

cost effective.

• Where activity is low, it may be sensible to consolidate services and concentrate expertise. This is the

model of care generally applied to more specialist services, which provide centralised care across a larger population. 1

20

CONFIDENTIAL Thanet CCG South Kent Coast CCG Canterbury & Coastal CCG CCG Ashford CCG

In In 2015/1 /16 ea east Ken ent t ha have a a tot

• tal

l pop populatio ion of

• f 695k,

, sug suggestin ing 0-1 Maj ajor r Em Emergency Cen entr tres with th spe specia iali list ser servic ices, 1-2 Em Emer ergency Cen entres and and 2-3 Med edic ical l Em Emergency Cen entr tres

Note: Includes just east Kent catchment population. Maternity and paediatrics not included. Source: 1 EK Case for Change 2016 Source: Sir Bruce Keogh, Transforming Urgent and Emergency care services in England, End of Phase 1 Report, 2014

Keogh recommends a catchment population of:

• 1. 1 to 1.5 million for a Major Emergency Centre

with specialist services

• 2. 500 to 700K for an Emergency Centre
• 3. 250 to 300k for a MedEC

The 15/16 projected catchment population suggests that east Kent can sustain:

• no more than 1 Major Emergency Centres with

specialist services (pPCI serves whole of K&M, serving a population of 1.2million)

• no more than 2 Emergency Centres (of which 1 will be

the MEC)

• 2 to 3 (of which 1 to 2 will be ECs) Medical Emergency

Centres

145 209 210 131

Population 20/21 (thousands)

21

CONFIDENTIAL

Is Is the the op

• pti

tion cli clinic icall lly sus sustain inable le over r the the med ediu ium to

• lon
• ng term

erm?

1. One Major Emergency Centre with specialist services based on the catchment size

• f the east Kent population and other services provided to a wider population

2. No more than two Emergency Centres (one of which will also be a Major Emergency Centre with specialist services) based on the catchment size of the east Kent population and throughput 3. 2 to 3 Medical Emergency Centres (one of which will also be a Major Emergency Centre with specialist services) based on the catchment size of east Kent population and the workforce available

22

CONFIDENTIAL

A num number r of

• f spe

specia iali list ser servic ices ar are e curr currently ly pr provid ided in n ea east t Ken ent, and and the these ser serve muc uch lar arger r pop popula latio ions

Service Dartford & Gravesham Medway Tunbridge Wells Maidstone WHH K&C QEQM Catchment 24 hours primary percutaneous coronary intervention (pPCI) x x x x ✓ x x 1.7m Urgent maxillo-facial surgery and oncology x x x x ✓ x x 990k Renal inpatients x x x x x ✓ x 990k Vascular No arterial work ✓ minor x x ✓ x 710k1

SOURCE: Google maps; Carnall Farrar Analysis. Travel times, 14 Feb 2017 10:00, driving 1 - Plans to create a single arterial centre for K&M will mean that Vascular Surgical services will serve a population of around 1.4M

Substantial numbers of people would travel over 2 hours for specialist services if they were not

• ffered in east Kent, suggesting a MEC with specialist services is required

23

CONFIDENTIAL

Is Is the the op

• pti

tion cli clinic icall lly sus sustain inable le over r the the med ediu ium to

• lon
• ng term

erm?

1. One Major Emergency Centre with specialist services based on the catchment size

• f the east Kent population and other services provided to a wider population

2. No more than two Emergency Centres (one of which will also be a Major Emergency Centre with specialist services) based on the catchment size of the east Kent population and throughput 3. 2 to 3 Medical Emergency Centres (one of which will also be a Major Emergency Centre with specialist services) based on the catchment size of east Kent population and the workforce available

24

CONFIDENTIAL WHH K&C QEQM

Th The e volu

• lume of
• f majo

ajor ED ED atten endances sug suggests the there is s suf suffic icient thr throughput for

• r tw

two

• Emer

ergency Cen entres, an and the therefore the there cou

• uld be

be on

• ne or
• r tw

two

• Emer

ergency Cen entr tre si sites

Source: 1 Provider returns 2015/16 Source: British Association for Emergency Medicine and The College for Emergency Medicine, Way Ahead, 2005

K&C Site QEQM 21,946 ED Majors1 46,901 WHH 42,304 47k 22k 42k Whilst the population catchment does not support more than one Emergency Centre, hospitals with attendances at ED in excess of 40,000 major attendances per year should have “immediate access to the key supporting specialties to allow an emergency department to function safely. The following should be available on site: intensive care, anaesthetics, acute medicine, general surgery, orthopaedic trauma. There should be rapid easy access to child health (preferable on-site), 24-hour access to imaging (including CT scanning) and laboratory services available on-site2”. In the Keogh model these services are provided at an Emergency Centre.

• east Kent had a total of 111,151 ED major attendances in 2015/16
• As Emergency Centres need a minimum throughput of 40k major ED attendances, east Kent could sustain a maximum of two of these Centres
• However, one of these Emergency Centres would also need to be the Major Emergency Centre with specialist services

111,151 Total

25

CONFIDENTIAL

Is Is the the op

• pti

tion cli clinic icall lly sus sustain inable le over r the the med ediu ium to

• lon
• ng term

erm?

1. One Major Emergency Centre with specialist services based on the catchment size

• f the east Kent population and other services provided to a wider population

2. No more than two Emergency Centres (one of which will also be a Major Emergency Centre with specialist services) based on the catchment size of the east Kent population and throughput 3. 2 to 3 Medical Emergency Centres (one of which will also be a Major Emergency Centre with specialist services) based on the catchment size of east Kent population and the workforce available

26

CONFIDENTIAL

Wha hat num number r of

• f Med

edic ical l Em Emergency Cen entres sho should ld be be con

• nsid

idered for

• r ea

east Ken ent?

Keogh recommends a catchment population of ~250-300K for a medical emergency centre.

Total east Kent Population 695K

Th This is sug suggest tha that we e sho should ld be be con

• nsiderin

ing tw two

• Med

edic ical l Emer ergency Cen entr tres in in ea east Ken ent. t.

27

CONFIDENTIAL QEQM currently has 5.9 consultants* The Royal College of Physicians recommends that for an Acute Medical Unit (AMU) with 30 beds or less there is a requirement for 1 to 1.5 consultants

• n the AMU 8am-8pm

In order to provide 12 and 14 hour AMU consultant cover 10 consultants are required A combined rota at no more than 2 sites would allow this standard to be met Recommendation Are we currently able to meet this? WHH currently has 9.4 consultants* Which options achieve this?

SOURCE: Royal College of Physicians; Acute care toolkit 4 (2015); NHS provider information (2016) NOTE: *Acute physicians and HCOOP

In In add addit itio ion, to

• mee

eet t na nati tional l rec ecommendatio ions, the there is s curr currently ly onl

• nly suf

sufficie ient work

• rkforce to
• pr

provid ide a a Med edic ical l Em Emer ergency Cen entr tre at t tw two

• si

sites

• This evidence shows there is insufficient workforce to sustain Medical Emergency services across three sites
• This means east Kent can have no more than two Medical Emergency Centres due to catchment size and

workforce volumes

K&C currently has 5.0 consultants* *Please note: the above rotas refer to an AMU rota with Acute Physicians and Health Care of Older Person (HCOOP) consultants (for acute medicine, ambulatory and frailty assessment). The medical specialties for respiratory, cardiology, gastro-enterology, diabetes and rheumatology will provide specialty in-reach to provide specialist assessment and responsive care

28

CONFIDENTIAL

Is Is the the op

• pti

tion cli clinic icall lly sus sustain inable le?

1) Is it clinically sustainable? Criteria Implication Possible configurations

▪ Catchment suggests 0-1 MECS, 1-2

ECs and 2-3 MedECs.

▪ Specialist services catchment means

1 MEC

▪ Workforce and access mean 1-2 ECs ▪ Workforce limitations mean 2, not 3

MedECs 1. 1 MEC with specialist services 2. No more than 2 ECs 3. No more than 2 MedECs Is it clinically sustainable?

RECOMMENDATIONS The analysis shows that:

• The current catchment population in east Kent in 15/16 is c.695k (projected population in 20/21 is c.721k). However, many

services in EK including pPCI and renal are provided to a population of over 1m which would support a Major Emergency Centre with specialist services. People would have to travel long distances to access these services if they were not available in east Kent. Therefore there should be one Major Emergency Centre with specialist services in east Kent serving, as now, a wider Kent & Medway population.

• The current catchment population in east Kent in 15/16 is c.695k (projected population in 20/21 is c.721k) which suggests a

population is marginally above the catchment required for a single Emergency Centre in east Kent using the Keogh requirement of 500-700k. However, there is sufficient throughput through ED for two Emergency Centres but not three.

• There is sufficient catchment population and only a sufficient Acute Physician / HCOOP consultant workforce to provide a

Medical Emergency Centre at two sites in east Kent but not three. CONSEQUENCES OF THE RECOMMENDATIONS

• Only options where one site is a Major Emergency Centre with specialist services; a maximum of two Emergency Centre

sites; and two Medical Emergency Centre sites will go forward to be tested against the next hurdle criterion.

29

CONFIDENTIAL –

K&C WHH QEQM

Site Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 Option 8 Option 9

MEC MEC EC EC

ICH UCC ICH UCC ICH

MEC EC

UCC ICH

MEC EC EC

UCC ICH

MEC MEC EC

UCC ICH

Green field site

GFS

MEC

Single site

• n existing

site Closing a site

UCC

MEC MEC

Lon

• ng list

t of

• f op
• ptio

ions rem emain inin ing for

• r ur

urgent car are ser servic ices fol

• llo

lowing the the ana analysis is ag again inst t cli clinic ical l sus sustainabil ilit ity cri criterio ion

Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it

EC

MedEC MedEC MedEC MedEC MedEC MedEC

Emergency centre Integrated care hospital Urgent care centre Major emergency centre with specialist services None – no centre Medical Emergency Centre

30

CONFIDENTIAL

Ass ssessing the the impa pact of

• f hur

hurdle le crit criteri ria

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

31

CONFIDENTIAL

• Analysis carried out under the east Kent Clinical Strategy Board 2016 looked at the costs of building a new hospital on a

greenfield site or single site option on a current acute site;

• In this analysis it was assumed that 189 beds (identified as being surplus to requirement based on Carnell Farrar’s bed

modelling and population analysis) have already been removed;

• This analysis looked at total costs of this move, including cost involved in building the new estate which would be needed

such as land purchase and building costs;

• This placed the total cost of such a reconfiguration at £665.3*m. To re-provide with 300 beds will cost £752.4m;
• Given the east Kent’s current financial position, a greenfield site or single site option on a current acute site would be

financially prohibitive due to the new estate which would need to be built; and

• These costs would not be financially viable with the 20/21 timeframe agreed.

SOURCE: east Kent clinical strategy, 2016

Ana naly lysis is carr arrie ied out

• ut by ea

east t Ken ent sho shows tha that pr provis ision of

• f a

a ne new gree eenfie ield ld si site or

• r si

single le si site op

• pti

tion on

• n cur

current ac acute si site wou

• uld

ld be be fi financia ially ly pr proh

• hib

ibit itiv ive

*Detailed capital break down in appendix

32

CONFIDENTIAL

Analysis carrie ied ou

• ut

t by ea east t Ken ent shows th that t provision of

• f a new gr

greenfiel eld sit ite e or

• r sin

ingle gle sit ite e

• p
• pti

tion on

• n cu

current acu cute sit ite wou

• uld be fin

financiall lly prohibitiv ive: acu cute med edical l bed eds nee eeded in in east t Ken ent by 2021

1. Assumed occupancy rates range from 91% to 99% by trust 2. Assumed 1 ward = 24 beds. Source: Acute provider returns 15/16; Carnall Farrar analysis

Beds WHH K&C QEQM Total 15/16 acute medical beds1 235 211 216 662 20/21 acute medical beds 171 156 146 473 20/21 projected available space (total bed base – elective and non elective) 85 51 91 226

Estimated beds

• If acute medical services were to be consolidated onto one site in 2020/21, 473 beds would be needed. This suggests

that 20 acute medical wards would have to be housed on a single site2

• No one site in east Kent is large enough to take 473 acute medical beds without substantial building, which would be

expensive and take time. Accommodating acute medical beds alone would mean existing site capacity would have to be doubled

• This means acute medical services could not be consolidated practically onto one site in the timeframes

33

CONFIDENTIAL

• Analysis carried out under the east Kent Clinical Strategy Board 2016 looked at the costs of removing all services from one

site and reproducing them onto the other two sites;

• In this analysis, it was assumed that 189 beds, identified in the east Kent bed audit as being surplus to requirement, has

already been removed;

• This analysis looked at total costs of this move, including cost involved in building the new estate which would be needed

such as land purchase and building costs;

• This placed the total cost of such a reconfiguration at £436.9m*; To re-provide with 300 beds will cost £524m;
• Given the east Kent’s current financial position, re-locating services from K&C would be financially prohibitive due to the

new estate which would need to be built; and

• This analysis is indicative of costs which would be incurred in a closure or reprovision of any single site across east Kent.

These costs would not be financially viable with the 20/21 timeframe agreed.

SOURCE: east Kent clinical strategy , 2016

Ana naly lysis is carr arrie ied out

• ut by ea

east t Ken ent sho shows tha that the the clo closure of

• f one
• ne si

site and and rep eprovisio ion of

• f

ac accommodatio ion on

• n the

the rem emain inin ing ac acute si sites wou

• uld

ld be be fi financially ly pr proh

• hibit

itiv ive

*Detailed capital break down in appendix

34

CONFIDENTIAL

Rec ecent t ne new bui build lds de demonstr trates tha that t the the 20/2 /21 tim timeframe pr proh

• hib

ibits ts the the bui buildin ing of

• f a

a ne new ac acute gree eenfie ield ld si site

Source: NHS Trust websites, accessed 2016

Queen Elizabeth Glasgow (opened 2015) Cost to build: £842m Beds: 900 Cost per bed: c.£935,000 Time to secure funding: 3 to 5 years Time to build: 4 years Total time to deliver: 7 to 9 years Queen Elizabeth Birmingham (opened 2010) Cost to build: £545m Beds: 1,215 Cost per bed: c.£449,000 Time to secure funding: 3 to 5 years Time to build: 6 years Total time to deliver: 9 to 11 years Royal Derby Hospital (opened 2009) Cost to build: £334m Beds: 1,159 Cost per bed: c.£288,000 Time to secure funding: 3 to 5 years Time to build: 6 years Total time to deliver: 9 to 11 years

35

CONFIDENTIAL

Source: ERIC Returns 2016/17

ERIC IC retu turns show th that t EKH KHUFT hos

• spital build

ildings have e bee een built ilt more rec ecently th than th the e national average, suggesting in all options the Trust should capitalise on ‘fit for purpose’ existing es estate

• Existing estate should not be knocked down and re-built as acute sites across EKHUFT have fewer old buildings (’48-’64) than

the national average (8% EKHUFT average compared to 32% national average).

• This suggests that no new builds should be considered on the ground of age of current estate alone.

Percentage of estate built, split by date range of build % 15 22 11 16 1 3 71 9 54 31 21 41 18 31 8 19 5 23 10 20 30 40 50 60 70 80 90 100 William Harvey Hospital Queen Elizabeth The Queen Mother Hospital Kent & Canterbury Hospital National Average - Acute

36

CONFIDENTIAL

Th The e 6 f facet sur survey sugg suggests ts EK EKHUFT es estate is s in n rea easonable le con

• ndit

itio ion, sugg suggestin ing lar arge am amou

• unts of
• f ne

new es estate ar are e no not t ne needed for

• r qua

quali lity rea easons

Trust / CCG Synopsis GIA m2 Occupied m2 6 Facet Average Energy Cost / GIA Total backlog Cost (£) Cost to eradicate backlog per M

2 of Space

% Clinical Space (for Carter) Kent and Canterbury 56,023 55,81 4.8 24 17,390,000 310 67 Queen Elizabeth The Queen Mother Hospital 51,390 46,385 4.64 27 32,600,000 634 69 William Harvey Hospital 61,814 58,157 5.93 30 24,050,000 389 66 Average per site 60,659 57,650 5 26 24,680,000 406 67

Source: ERIC Returns 2016/17

4.80 4.64 4.80 5

37

CONFIDENTIAL

Is Is the the op

• pti

tion impl plementable le?

2) Is it implementable?

• Only current sites considered due to time

frame - any model at any site

• No greenfield site or single site option on a

current acute site to be considered due to timeframe and cost

• No fewer than 2 sites with acute medical beds
• No complete closure and reprovision of any

single site will be considered 1. WHH – any service can be here 2. QEQM – any service can be here 3. K&C – any service can be here 2) Is it implementable? Criteria Implication Possible configurations RECOMMENDATIONS The analysis shows that:

• The average timelines for a new build (including funding, planning and implementation), using traditional NHS capital and build routes, rule out

the implementability of any options which require significant build on a greenfield site or one site closure and reprovision of accommodation on the remaining acute sites;

• The current bed base across all three sites is forecast to reduce by 189 beds by 2020/21. However, it is too costly for acute medical beds to be

consolidated onto a single site

• Appropriate accommodation on existing sites should be used as much as possible before any new capacity is built

CONSEQUENCES OF THE RECOMMENDATIONS 1. Only current sites can be considered due to 20/21 timeframe agreed. Only options with services at current acute sites will go forward to be tested against the next hurdle criterion. 2. Options where one site is a Major Emergency Centre with specialist services; no more than two sites Emergency Centre/Medical Emergency Centre will go forward to be tested against the next hurdle criterion.

38

CONFIDENTIAL

K&C WHH QEQM

Site Option 1 Option 2 Option 3 Option 4 Option 5 Option 6

MEC MEC EC EC

ICH UCC ICH UCC ICH

MEC EC

UCC ICH

MEC EC EC

UCC ICH

MEC MEC EC

UCC ICH UCC

List of

• f rem

emain inin ing op

• ptio

ions tha that de deli liver r ur urgent care ser servic ices fol

• llowin

ing the the an analy lysis ag again inst im impl plementable le cri criterio ion

Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it

MedEC MedEC MedEC MedEC MedEC MedEC

Emergency centre Integrated care hospital Urgent care centre Major emergency centre with specialist services Medical Emergency Centre

39

CONFIDENTIAL

Ass ssessing the the impa pact of

• f hur

hurdle le crit criteri ria

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

40

CONFIDENTIAL

Do Does es th the e op

• pti

tion deliv eliver acc cces essible ser ervic ices?

Detailed access and travel analysis has been undertaken in order to test the remaining options against access

• criteria. The following conclusion was reached:

The following slides outline the analysis undertaken to draw this conclusion 1. No options fail the access criteria as all remaining options are within the access criterion of an average of 1-hour travel time by car

Note

• There is limited information about the standard or guidance on the time (minutes or hours) that a patient must travel as a factor to consider when looking into

redesigning the urgent and emergency care services. The 1 hour access criteria used was based on travel time that was tested with the public at the East Kent focused listening events (phase 1) held in February 2017 and was generally supported; and

• In addition, the stroke configuration decision support guide recommends that travel time for an urban area should ideally be 30 minutes and no more than 1 hour.

K&M covers many rural areas and stroke is one of the key urgent and emergency care services provided in East Kent which further supported the 1 hour cut off.

41

CONFIDENTIAL

• The “impacted population” is the population whose nearest site will be impacted by a reconfiguration i.e. their

nearest service location will change

• We look at impacted population rather than the total population to assess the impact of location change on people

who are specifically affected by this change

• Illustrative example of the impacted population:
• Susan’s closest site offering a service is currently WHH
• In reconfiguration option 1 WHH will no longer be offering the service
• Susan’s closest site offering a service will therefore change to the next nearest site based on travel times
• Susan is a member of the impacted population

Travel l tim time ana analysis onl

• nly con
• nsid

iders tho those affected by ser services movi ving away fr from

• m the

their ir clo closest t si site in in ter erms of

• f tr

travel l tim time

QEQM

Population for whom QEQM is the closest site = not the impacted population Population for whom K&C is the closest site = not the impacted population

K&C WHH

Population for whom WHH is the closest site = the impacted population

42

CONFIDENTIAL

All l op

• ptio

ions with th onl

• nly one
• ne Em

Emer ergency Cen entr tre located in n ea east Ken ent t allo allow all all pa patie ients ts ac access to

• a

a si site (eit (either r in in K& K&M or

• r pe

peri riphery ry) ) with ithin 60 60 minu inutes

*Impacted population means that only the population whose closest service location in terms of travel time changed is analysed, the maximum this is taken as an average of the 5 longest minimum travel times SOURCE: Base map; Carnall Farrar Analysis. Travel times by car

If the EC was at WHH If the EC was at QEQM If the EC was at K&C

Site Configuration Option Maximum travel time for impacted population*

NOTE: This analysis assumes that for each option patients will travel to the next closest site in terms of travel time that is offering a service – this includes sites

• utside of East Kent

Peak

60 mins 50 mins 43 mins

43

CONFIDENTIAL

All ll op

• ptio

ions with ith tw two

• Emergency Cen

entres allo allow ac access to

• a

a si site (eit (either r in in K& K&M or

• r

pe perip iphery) with thin 45 45 minu nutes

*Impacted population means that only the population whose closest service location in terms of travel time changed is analysed SOURCE: Base map; Carnall Farrar Analysis. Travel times, peak, by car

If the ECs were at QEQM & WHH If the ECs were at K&C & QEQM If the ECs were at K&C & WHH Site Configuration Option NOTE: This analysis assumes that for each option patients will travel to the next closest site in terms of travel time that is offering a service – this includes sites outside of East Kent Peak 34 mins 43 mins 41 mins % impacted population able to access within X mins (peak) 30 45 60

100% 100% 100%

98.6% 1.4%

100% 100%

Maximum travel time for impacted population* (rounded to nearest whole minute)

23% 77%

37% 63%

81% 19%

44

CONFIDENTIAL

Is Is the the op

• pti

tion ac accessible le?

RECOMMENDATIONS The analysis shows that:

• If QEQM and WHH offer a service, 100% of the impacted population can access this service within 60 minutes
• If K&C and WHH offer a service, 100% of the impacted population can access this service within 60 minutes
• If K&C and QEQM offer a service, 100% of the impacted population can access this service within 60 minutes
• Therefore all remaining options meet this hurdle criterion

However, no option fails the access criteria of 60 minutes travel time The two site configuration that provide the best travel time for the majority of the east Kent population has services at QEQM and WHH CONSEQUENCES OF THE RECOMMENDATIONS

• No further options are removed

ICH/ UCC

• 3. Is it

accessible? No options fail the access criteria as all remaining options are within the average 1- hour hurdle criterion for access 1. WHH – any service can be here 2. QEQM – any service can be here 3. K&C – any service can be here Criteria Implication Possible configurations

45

CONFIDENTIAL

K&C WHH QEQM

Site Option 1 Option 2 Option 3 Option 4 Option 5 Option 6

MEC MEC EC EC

ICH UCC ICH UCC ICH

MEC EC

UCC ICH

MEC EC EC

UCC ICH

MEC MEC EC

UCC ICH UCC

List of

• f rem

emain inin ing op

• ptio

ions tha that de deli liver r ur urgent care ser servic ices fol

• llowin

ing the the an analy lysis ag again inst ac accessibili lity cri criterio ion

Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it

MedEC MedEC MedEC MedEC MedEC MedEC

Emergency centre Integrated care hospital Urgent care centre Major emergency centre with specialist services Medical Emergency Centre

46

CONFIDENTIAL

Ass ssessing the the impa pact of

• f hur

hurdle le crit criteri ria

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

47

CONFIDENTIAL

Is Is the the op

• pti

tion a a str trategic ic fi fit? t?

• 2014-19 EKHUFT strategic plan highlights local access to services as a priority in east Kent which is a central theme of the

NHS Five Year Forward View.

• Future options for changes to services should be aligned with existing commitments, in particular to ensure the continued

sustainability of workforce and compliance with Royal College requirements, the central drivers for previous consultations.

• Existing commitments have been defined as:

Designation processes: Existing sites have a national designation for service provision which has gone through an agreed process Consultations: Ensure that the options taken forward address the reasons underpinning previous consultation, predominantly workforce and Royal College driven.

• An analysis was carried out to test the options against these existing commitments and the following conclusions were

drawn: The following slides outline the analysis undertaken to draw this conclusion. 1. A Trauma Unit was located at WHH as part of a national designation process. As per the Keogh model and the clinical Senate recommendations the trauma unit must be part of a Major Emergency Centre with specialist services due to co-dependencies between services. 2. A 24/7 primary PCI centre for the whole of Kent was located at WHH as part of a national designation process. The pPCI centre should ideally be part of a Major Emergency Centre with specialist services due to co-dependencies between services. 3. Previous consultations in east Kent have concentrated on addressing workforce sustainability issues and Royal College

• requirements. Only options that continue to address these issues will be taken forward as part of this criteria.

48

CONFIDENTIAL

1. A Trauma Unit was located at WHH as part of a national designation process. The trauma unit must be part of a Major Emergency Centre with specialist services due to co-dependencies between

• services. Therefore in a two sited option the WHH should ideally be the Major Emergency Centre

with specialist services. 2. A 24/7 primary PCI centre for the whole of Kent was located at WHH as part of a national designation process. The pPCI centre should ideally be part of a Major Emergency Centre with specialist services due to co-dependencies between services. Therefore in a two sited option the WHH should ideally be the Major Emergency Centre with specialist services. 3. Previous consultations in east Kent have concentrated on addressing workforce sustainability issues and Royal College requirements. Only options that continue to address these issues will be taken forward as part of this criteria.

Is Is the the op

• pti

tion a a str trategic ic fi fit? t?

49

CONFIDENTIAL

• The designation process was developed in response to national

requirements set out in the revised NHS National Operating Framework.

• It involved the development of local trauma units to provide

enhanced services for patients following major trauma, and links with rehabilitation pathways for all patients following treatment for major

• trauma. Patients within 45 minutes of a major trauma centre (MTC)

will be taken straight there for treatment; patients further than 45 minutes will be taken to trauma units (TUs) where their condition can be stabilised.

• The 45 minute travel timeline was established based on a consensus
• f expert clinical opinion.
• As there was an insufficient volume of patients to warrant a MTC

being established in K&M, it was agreed that King's College Hospital (KCH) in South London would take this position, building on established links and patient flows.

• Geographical constraints within K&M and the proximity of KCH meant

the Kent and Medway Critical Care and South East Trauma Network deemed it necessary to develop ‘enhanced’ trauma units to ensure that clinical expertise was available locally to meet the needs of seriously injured patients, including treatment of some patients and for stabilisation of patients prior to transfer to a MTC for specialist treatment.

• In order to determine which

K&M hospitals should become TUs the Kent and Medway Trauma Network (KMTN) analysed the incidence of trauma in K&M and produced isochrones showing the 45 minute road- travel times to local acute

• trusts. As a proportion of

patients would be subsequently transferred to the MTC, it was agreed that the TUs would be best placed on a route towards the MTC. Background Decision making Outcome

• Medway Maritime

Hospital, William Harvey Hospital and Tunbridge Wells Hospital were designated as trauma units in 2012. The Queen Elizabeth the Queen Mother Hospital was designated as a Local Emergency Hospital with Helicopter Emergency Medical Services (HEMS) support.

In In 2012, th the e Sou

• uth East

t Trauma Netw twork des esign ignated ed WHH as th the e tr trauma unit it for ea east t Ken ent as s part rt of

• f a natio

tional l des esign ignation proces ess

SOURCE: Proposal for the Development of Major Trauma Units for Kent and Medway , 2012, Major trauma care in east Kent2015

50

CONFIDENTIAL

• In 2010, the Kent Cardiac Network (South East)

agreed that the Kent and Medway primary PCI service should be established at the William Harvey Hospital, Ashford (WHH) in-line with the Commissioning intentions, National Policy, and best practice

• South East Clinical Senate also endorsed the

decision of the Kent Cardiac Network that the Kent and Medway primary PCI service should be established at the William Harvey Hospital, Ashford (WHH)

• Kent and Medway primary PCI service was agreed

to be provided from the catheter laboratory at William Harvey Hospital (WHH), Ashford. This facility has been approved by the British Cardiovascular Intervention Society (BCIS) since November 2005

• The WHH service was the nominated provider for all

patients requiring primary PCI who live within the boundaries of Eastern Coastal Kent, Medway and West Kent PCTs.

• In 2013, NHS England took over the commissioning

responsibility for primary PCI and the Kent-wide service was assessed as compliant against the national service specification

• The geographical location of WHH and associated

transfer times are critical in the successful delivery

• f the Kent primary PCI service.
• EKHUFT worked closely with the Kent Cardiac

Network and South East Coast Ambulance Service (SECAMB) to review the travel times and isochrone maps to ensure agreed call times can be met. These are as follows: ✓ ‘Call To Balloon’ (CTB) – 120 minutes ✓ ‘Door To Balloon’ (DTB) – 90 minutes

• Evidence from SECAMB supports the achievement
• f the above standards; the shortest times being

achieved by direct admission to the catheter laboratory in the primary PCI Centre at WHH. This evidence was submitted, discussed, reviewed and agreed by the Kent Cardiac Network Board

Background Decision making Outcome

• WHH was designated to

provide Kent and Medway primary PCI service.

In In 2010, th the e Ken ent t Ca Cardiac Network des esign ignated WHH as th the e pPCI Ce Centre e for

• r Ken

ent and Med edway as s part rt of

• f a natio

tional l des esign ignation process

51

CONFIDENTIAL

Key Additional services that should in-reach if not based on- site Co-location on same site Specialist services Support services

▪

Co-located

–

Social care

–

Physiotherapy

–

Occupational Therapy

–

Lab based diagnostics

–

Emergency imaging and reporting

▪

Ideally co-located

–

Speech and language therapy

–

Dietetics Source: [The Clinical Co-Dependencies of Acute Hospital Services: A Clinical Senate Review December 2014], Carnall Farrar analysis

• In-reach may be sufficient depending on ED pathways (required for a trauma unit)

*Non-specialised paediatrics and paediatric surgery

Acute cardiology Urology* Urgent GI endoscopy Anaesthetics Vascular surgery (spoke) Interventional cardiology (PC/i) Vascular surgery (hub)

• HASU
• Interventional radiology

Hyper acute stroke unit Acute stroke unit Inpatient rehabilitation Respiratory medicine Medical gastroenterology Critical care (L1, L2 & 3) Trauma Acute gynaecology General surgery Liaison psychiatry Acute paediatrics* Trauma unit

• Acute paeds

Acute and general medicine (inc. AMU) ENT* Consultant-led obstetrics Emergency Department (unselected) Elderly medicine Orthopaedics* Diagnostics inc. MRI Urgent haematology Clinical microbiology Interventional radiology Support services (see key) Rheumatology Dermatology Nephrology (not including dialysis) Maxillo-facial surgery Neurology Palliative care Acute oncology Plastic surgery Burns Diabetes & endocrinology Ophthalmology

A tr trau auma uni unit and and a a pP pPCI Cen entr tre mus ust be be co-dependent t with th a a Majo ajor Em Emer ergency Cen entre with ith spe specia iali list t ser servic ices fol

• llowin

ing Sou

• uth Eas

ast Coa

• ast

t Clin linic ical l Sen enate rec ecommendatio ions

52

In addition, there are key services provided at the WHH that support its development as a Major Emergency Centre

Th The e Keo eogh rep eport rt (20 (2014) ) se sets out

• ut the

the ser servic ices of

• ffered fr

from

• m a

a Majo ajor r Em Emer ergency Cen entre an and WHH alr already pr provid ide the these ser services

What Centre Services Currently Offered

• Larger units, capable of assessing

and initiating treatment for all patients and providing a range of specialist hyper-acute services

• Service population of

approximately 1-1.5m

Services WHH QEQMH Hyper-acute Cardiac (pPCI)* √ X Stroke √ √ Full Obstetrics √ √ level 3 NICU √ X Trauma unit √ X Level 3 ICU √ √

Single inpatient Head & Neck Unit (Ophthalmology, ENT and Maxillofacial including complex cancer activity) and therefore in all

• ptions where emergency services remain on two sites, the MEC with specialist services should be at the WHH and not QEQMH

* Single Kent & Medway Percutaneous coronary intervention (PCI) since 2010

Major Emergency Centre with Specialist Services

53

CONFIDENTIAL

Is Is the the op

• pti

tion a a str trategic ic fi fit? t?

1. A Trauma Unit was located at WHH as part of a national designation process. The trauma unit must be part of a Major Emergency Centre with specialist services due to co-dependencies between

• services. Therefore WHH should ideally be the Major Emergency Centre with specialist services.

2. A 24/7 primary PCI centre for the whole of Kent was located at WHH as part of a national designation process. The pPCI centre should ideally be part of a Major Emergency Centre with specialist services due to co-dependencies between services. Therefore WHH should ideally be the Major Emergency Centre with specialist services. 3. Previous consultations in east Kent have concentrated on addressing workforce sustainability issues and Royal College requirements. Only options that continue to address these issues will be taken forward as part of this criteria.

54

CONFIDENTIAL

ea east Ke Kent has has und undertaken thre three pre previo ious con consult ltation whi hich rec reconfig igured em emerg ergency ca care serv servic ices

Other east Kent consultations undergone but not referenced here due to relevance are ‘Changes to services in Dover’ June – Sep 2006 and ‘east Kent area Improvements to Outpatient Services’ Dec 2013 - March 2014

SOURCE: Modernising hospital services in east Kent- Executive Summary (2001), Advice on NHS service change in east Kent (2003), east Kent Maternity Services Review (2012)

Dates Consultation Key service changes/Impact / Outcome 1 Dec 2001 - Feb 2002 Modernising Hospital services in east Kent

• Reviewed A&E and general medicine, renal, dermatology, urology,

vascular, cancer, cardiology, neurology, acute obstetrics and gynaecology, in-patient and ambulatory paediatrics, Trauma & Orthopaedic services, NICU and general and colorectal surgery;

• The A&E at K&C was redesigned as a local Emergency Care Centre which,

in 2015, became the GP led Urgent Care Centre and the Acute Medical

• Unit. The key reason was due to junior doctor training requirements;
• Reconfiguration of services across the Trust was successfully completed in

2006 2 July 2003 - Oct 2003 East Kent Hospitals Reconfiguration Plan

• Inpatient elective orthopaedic surgery, inpatient breast surgery, inpatient

neurology, dermatology and inpatient clinical haematology 3 July 2003 - Sep 2003 Kent and Medway review of Renal and vascular services

• Review of Kent and Medway’s renal, vascular surgical and interventional

radiology services 4 Oct 2011 - Jan 2012 Maternity reconfiguration

• Changes to maternity service which included co-location of midwifery-led

units at WHH and QEQM and the closure of the stand-alone midwife-led units at K&C and Buckland Hospital Dover (BHD)

55

CONFIDENTIAL

Th The e 2003 Em Emergency ser services rec econfiguratio ion

Several important issues regarding workforce required EK Hospitals to reconfigure clinical services in 2001 and again in 2003. These issues were:

• Royal College’s recommendations that the expertise that is needed to treat less common or more complex

diseases can only be provided in east Kent if specialties are divided into ‘sub-specialties’ which allow the doctors and other clinical staff to see enough cases to remain expert;

• Working time legislation for all staff but especially junior doctors meant doctors would work less hours and

clinical areas needed to be staffed 24/7;

• Doctors are required to work in teams for their specialty to maintain patient safety; and
• A national shortage of skilled nurses, doctors and therapists in some specialties was making recruitment

increasingly difficult. For these reasons it was not possible to provide all of the current specialties (especially surgical) on all three sites and some services would need to be consolidated onto fewer sites to allow staff and resources to be maximised, meet national guidelines and deliver high quality services. The following were the core service changes:

• A&E at K&CH removed and redesigned as a local Emergency Care Centre (which later (2015) became the GP

led Urgent Care Centre and the Acute Medical Unit. The key reason was due to junior doctor training requirements);

• A&E Departments were established at WHH and QEQM alongside:
• Consultant-led Women's Health services on two sites (WHH and QEQM);
• In-patient Paediatrics on two sites (WHH and QEQM);
• General and Colorectal surgery on two sites (WHH and QEQM).
• Trauma and orthopaedic services on two sites (WHH and QEQM);
• The consultations also established a single site specialty service for renal inpatients, head and neck, urology,

vascular and Neonatal intensive care unit (NICU) due to volume.

• For east Kent, the consultations also established a children’s ambulatory development and assessment centre

at K&CH

SOURCE east Kent Hospitals Reconfiguration Plan – 2003 Public Consultation Document

56

CONFIDENTIAL

Previ vious con

• nsult

ltatio ion: History ry of

• f the

the de decis ision-makin ing pr process for

• r east Kent’s two-sit

ite Acu cute Inp Inpatie ient Mod

• del
• East Kent Health Authority - Tomorrow’s Healthcare concluded that it was not possible to retain major and complex services on all three main

hospital sites.

• The Case for Change was developed and criteria established. These were:
• i. Safety – “when I get there does the service have the right staff and backup to ensure speedy, safe and up to date treatment and to ensure fast

recovery?”;

• ii. Accessibility – “how quickly can I get to the service I need when I need it or how quickly can it get to me?”
• iii. Viability – “Will the service last or will there be more service changes in a few years’ time?”
• iv. Affordability – The Health Service must get as much treatment as possible for as many people as possible from the taxpayers’ money. Is the

taxpayers’ money being used to best effect?”

• A short list of options were assessed using the above criteria. These were:

i. Single site at Canterbury

• ii. Bipolar – Thanet and Ashford
• iii. Bipolar – Canterbury and Ashford
• The Health Authority commissioned Deloitte & Touche to undertake a social and economic impact statement to help inform the Health Authority’s

final decision. Travel times were identified as particularly important for east Kent’s population but the assessment also considered levels of deprivation, travel by blue light transport, vehicle ownership, demographic spread including age, staffing impact.

• Deloitte & Touche’s final report concluded that “the socio-economic analysis indicates the impact of acute hospital services relocation from QEQMH

will be greatest”.

• A further detailed analysis of travel times was then undertaken by Kingswood Consultants to establish the impact of the proposed options on service
• accessibility. The main findings from this work were:

i. For ‘blue light’ ambulance coverage, is little difference between a Thanet and Ashford and a Canterbury and Ashford option;

• ii. In rush hour conditions a Thanet and Ashford option gives better coverage than a Canterbury and Ashford option;
• iii. A Thanet and Ashford option has the least impact on accessibility for those aged over 65, those households without a car and those households

which are economically active but unemployed; and

• iv. For emergency inpatient activity, the option which would have the best accessibility for the majority of specialties is a Thanet and Ashford option.

Source: The Future of Hospital Services in east Kent, June 1989, east Kent Health Authority ; Economic and Social Impact, Deloitte & Touche, May 1998; Moving Forward: A strategic outline case for modernising hospital services in east Kent, 2001; Modernising Hospital Services in east Kent 2001 to 2005 Consultation Document. east Kent NHS; Independent Reconfiguration Panel, ADVICE ON NHS SERVICE CHANGE IN east Kent, Submitted to the Secretary of State for Health, 12 June 2003; Concern for Health In east Kent vs east Kent Hospitals NHS Trust and Kent & Medway Health Authority, Nov 2002.

57

CONFIDENTIAL

Previo ious con

• nsult

ltatio ion: His istory ry of

• f the

the de decis ision-makin ing pr process for

• r east Kent’s Two-sit

ite Acu cute Inp Inpatie ient Mod

• del
• The Health Authority stated that its preferred option for the location of specialist services was in Ashford and Margate with supporting services

provided in Dover and Canterbury stating this configuration “would provide the optimum access to the most people with the greatest need for NHS services”.

• Public Consultation - The Future of Hospital Services in east Kent (also known as A Better Balance). The preferred option was referred to the then

Secretary of State for Health who endorsed the proposals.

• Final public consultation undertaken - Modernising Hospital Services in east Kent. All options concentrated acute services (to varying degrees) and

full A&E at Ashford and Margate.

• Following the consultation, east Kent’s four Primary Care Trusts met and recommended that the future configuration of acute services in east Kent

should see:

• i. acute medical services provided on two sites - William Harvey Hospital (WHH), Ashford, and the Queen Elizabeth the Queen Mother Hospital

(QEQM), Margate;

• ii. elective medicine should be provided on three sites – the WHH, the QEQM and the Kent and Canterbury Hospital (K&CH);
• iii. other elective services should be provided on three sites – the WHH, the QEQM and the K&CH;
• iv. K&C should have a diagnostic and treatment centre (DTC).
• Two Community Health Councils (CHC) Challenge – the Canterbury and Thanet CHC and the South east Kent CHC – formally objected to the proposals

and asked that the matter be referred to the Secretary of State for Health on the grounds of clinical viability, safety and sustainability inadequate bed capacity proposals and inadequate consultation. The Secretary of State for Health then asked for an independent review of the proposals by the Independent Reconfiguration Panel (IRP).

• The IRP concluded that the interim proposals (i.e. two A&Es at WHH and QEQMH and an ECC at K&CH) represented the speediest and most efficient

means of proceeding in the interest of the people of east Kent.

• There was a further challenge around the decision to reduce the provision of services at K&CH. Challenge was unsuccessful – as detailed in the

Independent Reconfiguration Panel report ‘Advice on NHS Service Change in east Kent’ Submitted to the Secretary of State for Health, 12 June 2003

Source: The Future of Hospital Services in east Kent, June 1989, east Kent Health Authority ; Economic and Social Impact, Deloitte & Touche, May 1998; Moving Forward: A strategic outline case for modernising hospital services in east Kent, 2001; Modernising Hospital Services in east Kent 2001 to 2005 Consultation Document. east Kent NHS; Independent Reconfiguration Panel, ADVICE ON NHS SERVICE CHANGE IN east Kent, Submitted to the Secretary of State for Health, 12 June 2003; Concern for Health In east Kent vs east Kent Hospitals NHS Trust and Kent & Medway Health Authority, Nov 2002.

58

CONFIDENTIAL

Th The e 2011/2 /2012 Maternit ity ser servic ices rec econfig iguratio ion

Maternity services reconfiguration

• The option to co-locate midwifery-led units at WHH and QEQM was chosen on the basis of a

series of analysis which looked at travel times, patient flows and workforce impacts;

• The travel time analysis carried out for this consultation supported the placement of services on

the grounds of access;

• This analysis concluded that co-locating midwifery-led units at WHH and QEQM and closing the

stand-alone midwife-led units at K&CH and Buckland Hospital Dover (BHD) would give the following beneficial outcomes:

• There would be a better distribution of staff across sites and a more sustainable service as

concentrating staff across two sites instead of four would mean unexpected closures due to lack of staff was less likely;

• A new midwife-led birth centre in Margate (co-located with the acute obstetric ward) would
• pen to provide four extra labour/postnatal beds;
• An increase in births at Ashford would be possible in the midwife-led unit and two more labour

beds would soon be available; and

• 25 per cent of women who transfer to a consultant-led centre due to complications would no

longer need an ambulance journey.

SOURCE Joint Maternity Services Review public consultation document, 14 October 2011

59

CONFIDENTIAL

77 77 % % of

• f the

the im impa pacted po popula latio ion ar are ab able le to

• ac

access ur urgent t car are ser services with ithin in 30 minu nutes if f the the tw two

• Med

edECs si sites ar are e located QEQM and and WHH

*Impacted population means that only the population whose closest service location in terms of travel time changed is analysed, the maximum this is taken as an average of the 5 longest minimum travel times SOURCE: Base map; Carnall Farrar Analysis. Travel times, by car

If the Med ECs were at QEQM & WHH If the Med ECs were at K&C & QEQM If the Med ECs were at K&C & WHH

Site Configuration Option

Maximum travel time for impacted population*

Peak

34 mins 43 mins 41 mins

QEQM & WHH come out to be better with improved outcomes for patients. This was the same in 2013 and 2012 consultation which further support the conclusion of two end access

30 minutes access

Peak

23% 77% 37% 63% 81% 19% Able to access site within 30mins Not able to access site within 30mins

Note for Peak

• Only 23% of the impacted population are able to access urgent care services within 30 minutes if the 2 sites are at K&C and WHH
• This is significantly worse than the 81% who are able to if the 2 sites are at QEQM and WHH

60

CONFIDENTIAL

Is Is the the op

• pti

tion a a str trategic ic fi fit? t?

RECOMMENDATIONS The analysis shows that for options where emergency services are planned on two sites:

• All previous analysis undertaken as part of public consultations demonstrates that under a two-site option, QEQMH and WHH provide the greatest

accessibility for east Kent residents;

• A national designation process for trauma services has already placed the trauma unit at WHH which ideally should be the major emergency

centre with specialist services;

• The national designation process for K&M pPCI services put the pPCI centre at at WHH which ideally should be major emergency centre with

specialist services;

• The clinical co-dependencies recommended as part of the Keogh review and the work commissioned from the South East Coast Clinical Senate

support that the WHH should be the MEC with specialist services under a two-site solution for east Kent;

• Given this analysis the hurdle criteria would place the MEC at WHH and either an EC or MedEC at QEQM. The first hurdle criteria has already

ruled out a third EC or MEC and therefore K&CH cannot be a MedEC or a MEC. CONSEQUENCES OF THE RECOMMENDATIONS The only two-site options taken forward to be tested against the next hurdle criteria will be where WHH is the Major emergency centre with specialist services. Under this two site option:

• QEQM could either be an Emergency centre (EC)and/or a Medical emergency centre (MedEC);
• K&CH would always be an integrated care hospital (ICH)/Urgent care centre (UCC).

4) Is it a strategic fit?

• Trauma unit designated at WHH due to location –

therefore WHH must be MEC

• pPCI designated at WHH due to location – ideally

should be MEC

• QEQM could either be an Emergency centre (EC)and/or

a Medical emergency centre (MedEC)

• K&CH would always be an integrated care hospital

(ICH)/Urgent care centre (UCC) 1. WHH – MEC with specialist services 2. QEQM – EC, MedEC 3. K&C – ICH/UCC Criteria Implication Possible configurations

61

CONFIDENTIAL

K&C WHH QEQM

Site Option 4 Emergency centre Integrated care hospital Urgent care centre Major emergency centre with specialist services UCC ICH

MEC EC

List of

• f rem

emain inin ing op

• ptio

ions tha that de deli liver r ur urgent care ser servic ices fol

• llowin

ing the the an analy lysis ag again inst str trategic fi fit t cri criterio ion

Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it

MedEC

Medical Emergency Centre

62

CONFIDENTIAL

Ass ssessing the the impa pact of

• f hur

hurdle le crit criteri ria

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

63

CONFIDENTIAL

Ass ssessing whe hether r the the op

• ptio

ions ar are e fi financia iall lly via viable le over er the the med ediu ium term erm to

• lon
• ng

ter erm

• The high level financial implications of remaining options needs to be assessed to establish if

any of these options would adversely impact getting the system to financial balance by 2020/21 as detailed in the October 2016 Sustainability and Transformation Partnership (STP) submission. We are aiming to eliminate any options which do not contribute to a financially viable solution. In the next phase, a detailed economic model will be developed to understand the financial implications of the recommended options at a greater level of granularity.

64

CONFIDENTIAL

Closin ing the the pr proj

• jected fi

financia ial l gap ap acr across K& K&M will ll be be sup support rted bu but t not not driv driven by ac acute rec econfig iguratio ion

Notes: 1 Includes 7 day services, GP forward view, increased capacity for CAHMS and eating disorders, implementing mental health task force and cancer task force, maternity review, digital road maps, investment in prevention. Source: STP financial template

• 29
• 434
• 139
• 294

STF investment

• 122

122 Enablers Financial challenge, 2020/21, post- intervention STF funding 12 System Leadership TBC Spec Comm QIPP Provider challenge CCG challenge QIPP Productivity

• incl. CIP

102 51 Social care challenge Total system challenge 190 Care Trans- formation 50

£ millions, Kent and Medway health system

• Outstanding gap relates to £29m funding

for Ebbsfleet growth by 2020/21

• Also a capital implication of £75m
• Assumes 100% investment of STF funding to deliver

transformational change and service developments

• Further work required to refine this need

65

CONFIDENTIAL

• Staff savings from consolidation/networking of rotas
• Consolidation of elective activity
• Consolidation of support services
• Removing stranded estate
• Impact of QIPP
• Note: assume there is no additional agency or clinical / non-clinical supply

cost benefits as these are being recognised by the productivity opportunity

Th Ther ere will ll be be bot both fi financia ial l be benefit its an and cos

• sts fr

from

• m consolid

idatin ing ser services whi hich will ll ne need to

• be

be wor

• rked thr

throu

• ugh as

as pa part t of

• f the

the ne next t eval aluatio ion of

• f op
• ptio

ions

+ The following will result in savings from making changes

• These items will be an

additional cost pressure from making changes

• Additional transportation costs
• Capital charges / implications from capital investment
• Transition costs
• Communications and public consultation

The benefits and costs will be analysed in granular detail at the evaluation stage. It is assumed that the

• verall revenue costs (excluding revenue costs of capital) of consolidation do not differentiate between
• ptions at the hurdle criteria stage.

66

CONFIDENTIAL

High level service changes under this scenario

• All inpatient activity moves from the K&C site
• Vascular, renal, urology/uro-oncology move to WHH from K&C
• Emergency surgery, inpatient paediatrics, maternity, gynaecology, gynae-oncology moves from QEQM
• All Totals above are at 85% occupancy
• Outflow from EKHUFT hospitals would be minimal (21 inpatient beds). However, there is often only 2 or 3 minutes difference in travel time to WHH versus

MMT so patients may flow differently to predicted.

• The bed capacity exists at QEQM but additional bed capacity would need to be built at WHH to accommodate the additional surgical activity.

Source: EKHUFT HES data March 2017, Basemap travel time data, off peak car. An additional 24 beds will be required at WHH if the planned vascular consolidation is implemented.

If If QEQM is is a a Med edic ical l Emer ergency Cen entre, it it wou

• uld

ld req equire 136 ad addit itional l be beds at t WHH WHH

Actual beds 15/16 Growth by 20/21 20/21 local care interventions After service reconfiguration Final Bed Requirement Sites Baseline Increase Demand New Total Reduction New Total Bed Changes Total Required Bed Balance WHH 447 124 571

• 193

378 +205 583

• 136

QEQM 368 121 489

• 197

292 +7 299 +69 K&C 277 48 325

• 92

233

• 233

+277 Total 1,092 293 1385

• 482

903

• 21

882 210

Inpatient beds

67

CONFIDENTIAL

High level service changes under this scenario

• All inpatient activity moves from the K&C site
• Vascular, renal, urology/uro-oncology move to WHH from K&C
• Elective (IP) work moves from WHH (general surgery, orthopaedics, urology)
• Emergency surgery, inpatient paediatrics, maternity, gynaecology, gynae-oncology moves from QEQM
• All bed totals above are at 85% occupancy except the baseline
• Outflow from EKHUFT hospitals would be high (47 inpatient beds) and the majority of this outflow would be elective work (26 beds are elective). The difference

in travel time compared to QEQM is significant so it is unlikely that this analysis would change significantly with refreshed or peak travel data. Some of this work may be directed to QEQM if outpatient work remains at WHH.

• Additional bed capacity would still need to be built at WHH for surgical activity even if elective orthopaedic activity is transferred elsewhere

Source: EKHUFT HES data March 2017, Basemap travel time data, off peak car. Note: 1 bed shown remaining at K&C because of activity which does not have an associated LSOA (postcode). Modelling assumes vascular arterial centre and HASU located at WHH, pending outcome of vascular review and stroke review. This does not assume this decision is made and is for modelling purposes only. An additional 24 beds will be required at WHH if the planned vascular consolidation is implemented

Even if f ele electiv ive act activ ivity ty is s rem emoved fr from

• m WHH, 92 add

additio ional l be beds wou

• uld

ld be be req equired for

• r QEQM to
• be

be an an Med edic ical l Emer ergency Cen entr tre

Actual beds 15/16 Growth by 20/21 20/21 local care interventions After service reconfiguration Final Bed Requirement Sites Baseline Increase Demand New Total Reduction New Total Bed Changes Total Required Bed Balance WHH 447 124 571

• 193

378 +161 539

• 92

QEQM 368 121 489

• 197

292 +25 317 +51 K&C 277 48 325

• 92

233

• 233

+277 Total 1,092 293 1385

• 482

903

• 47

856 236

Inpatient beds

68

CONFIDENTIAL

Is Is the the op

• pti

tion fi financially ly via viable?

RECOMMENDATIONS The analysis shows that:

• It is assumed that the overall revenue costs (excluding revenue costs of capital) of consolidation is not a differentiating factor

between options at the hurdle criteria stage. Therefore only the impact on capital costs is analysed further at this stage.

• The remaining options being tested are QEQM as an Emergency Centre or Medical Emergency Centre.

– Options where QEQM is a Medical Emergency Centre results in high levels of flows to WHH (136 beds and 92 beds in the two previous slides) and the cost of capital for these options will be excessive. – QEQM must therefore be an Emergency Centre (and Medical Emergency Centre) under a two-site option. CONSEQUENCES OF THE RECOMMENDATIONS

• Under a two-site option, QEQM is an Emergency Centre under all options.
• Further work needs to be undertaken regarding the use of K&CH as ICH /UCC.

Is it financially sustainable?

• Under a two-site option, QEQM is an EC

as capacity required due to patient flows is too large for WHH to accommodate 1. WHH – MEC with specialist services 2. QEQM –EC 3. K&C – ICH/UCC Criteria Implication Possible configurations

69

CONFIDENTIAL

K&C WHH QEQM

Site Option 4 Emergency centre Integrated care hospital Urgent care centre Major emergency centre with specialist services UCC ICH

MEC EC

Rem emainin ing op

• ptio

ions tha that de deli liver r ur urgent t car are ser services fol

• llo

lowin ing the the an analy lysis is ag again inst fi financial sus sustain inabil ility ty cri criterio ion

Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it

70

CONFIDENTIAL

Criteria Implication 1) Is it clinically sustainable? 3) Is it accessible? 5) Is it financially Sustain- able? 4) Is it a strategic fit? 2) Is it Implementa- ble?

*All MECs are also a EC and an MedEC, all ECs are also an MedEC

▪ Catchment suggests 0-1 MECS, 1-2 ECs and 2-3 MedECs. ▪ Specialist services catchment means 1 MEC ▪ Workforce and access mean 1-2 ECs ▪ Workforce limitations mean 2, not 3 MedECs

• Trauma unit designated at WHH due to location – therefore must be MEC
• pPCI designated at WHH due to location – ideally should be MEC
• QEQM could either be an Emergency centre (EC)and/or a Medical emergency

centre (MedEC)

• K&CH would be an integrated care hospital (ICH)/Urgent care centre (UCC)
• Under a two-site option, QEQM is an EC as capacity required due to patient flows

is too large for WHH to accommodate

• Only current sites considered due to time frame - any model at any site
• No greenfield site or single site option on a current acute site to be

considered due to timeframe and cost

• No fewer than 2 sites with acute medical beds
• No complete closure and reprovision of any single site will be considered
• No options fail the access criteria as all remaining options are within the

average 1-hour hurdle criterion for access Possible configurations 1. 1 MEC with specialist services 2. No more than 2 ECs 3. No more than 2 MedECs 1. WHH – any service can be here 2. QEQM – any service can be here 3. K&C – any service can be here 1. WHH – MEC with specialist services 2. QEQM – EC, MedEC 3. K&C – ICH/UCC 1. WHH – MEC with specialist services 2. QEQM –EC 3. K&C – ICH/UCC 1. WHH – any service can be here 2. QEQM – any service can be here 3. K&C – any service can be here

Sum ummary ry of

• f the

the app applic icatio ion of

• f Hur

urdl dle Crit riteria ia ag again inst t EK EK ur urgent t car are op

• ptio

ions

71

CONFIDENTIAL

Urgent care services Background

Con

• ntents

Appendix Applying the hurdle criteria on urgent care options Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Single site developer options at K&CH Agreed K&M Fixed Point Criteria

72

CONFIDENTIAL

In Intr troductio ion of

• f a

a si single le si site de developer r op

• pti

tion at t K& K&CH

• The hurdle criteria evaluation eliminates the option to create a single site on an existing site or on a green field site due to this option

failing the “implementable” criteria. The key reasons are the capital cost would be too high and the timeline for delivery would be too long.

• In the summer of 2017, proposals for Canterbury were received from a developer. The proposal was explored with Deloitte’s to

understand high level viability.

• The proposal included a fully serviced new shell building of around 450,000 sq ft (subject to further review, discussion and

confirmation) attached to the Canterbury Hospital site with appropriate access and associated car parking for around 600 spaces.

• The building shell, car parking and associated infrastructure would be constructed and given to the Hospitals trust at nil cost at the
• utset. The Trust would not need to give up any of its existing land in order to facilitate the proposal.
• The proposal requires approval of additional housing as this would help fund the hospital development.
• The offer from the developer would significantly reduce the cost to the NHS of creating a single site solution to such an extent that we

believe it requires in depth evaluation. Furthermore, the timescales that have been put forward by the developer would mean that a single site option could be delivered within the timescales of the STP

• This proposal from the developer represents an opportunity to establish a major emergency centre with more specialist services at

Canterbury and would see services consolidated at this site from the Queen Elizabeth the Queen Mother hospital at Thanet and the William Harvey hospital at Ashford (with these hospitals no longer providing acute emergency care).

• This proposal was not included in the long list of options as it was not known prior to August 2017.
• Amending the hurdle criteria or the process that has been used to apply them is not appropriate and would undermine the work

undertaken to date.

• Whilst the proposal sits outside of the process undertaken to date, due to the materiality of the development, and in recognition of the

feedback received through engagement activities, it would be unreasonable not to consider the developer’s proposal.

• The proposal from the developer will be considered as an additional option and will be taken into account alongside the option that

comes out of the application of the hurdle criteria.

The proposal received from the developer is a material, unforeseen development that could not have been

• anticipated. Due to it being an unforeseen development it was not possible to take account of this within

the application of the hurdle criteria that has already been undertaken.

73

CONFIDENTIAL

Th The e ser servic ice mode

• del wou
• uld

ld see see the the de deli livery ry of

• f a

a si single le si site Majo ajor Em Emer ergency Cen entre with th Spe pecialis ist t ser servic ices in in ea east Ken ent t at t K& K&CH with ith sup support rtin ing pe perip ipheral l si sites

A single MEC would contain

• 24/7 emergency department with

trauma;

• Emergency services e.g. medicine;

HCOOP and surgery;

• In-patient gynaecology and
• bstetrics;
• In-patient child health services;
• Critical care;
• Trauma unit;
• Diagnostics;
• Interventional radiology;
• Specialist services:
• NICU / Special Care Baby Unit;
• Renal;
• Head and neck cancer (incl ENT);
• Vascular;
• Urological cancer;
• Haemat-oncology and

OP haemophilia;

• HASU & ASU;
• pPCI;
• Gynae-oncology.

Peripheral sites would provide:

• GP led UCC;
• outpatient services;
• fracture clinics;
• day surgery;
• ambulatory care;
• diagnostics;
• pharmacy;
• therapies;
• renal dialysis;
• chemotherapy;
• elective endoscopy;
• ambulatory paediatrics;
• maternity day care;
• neuro-rehabilitation beds;
• step up / step down beds.

Other opportunities for the peripheral sites

• Primary care;
• Social services;
• Community rehab;
• Voluntary services;
• Nursing home;
• Community services.

74

CONFIDENTIAL

Final l med ediu ium list for

• r Ur

Urgent Ca Care Options

Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it

K&C WHH QEQM

Site Option A Emergency centre Integrated care hospital Urgent care centre Major emergency centre with specialist services UCC ICH

MEC EC

Option B UCC ICH UCC ICH

MEC

75

CONFIDENTIAL

Urgent care services Background

Con Conten ents

Appendix Applying the hurdle criteria on urgent care options Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Single site developer options at K&CH Agreed K&M Fixed Point Criteria

76

CONFIDENTIAL

Stroke Vascular

• There are two hospitals in K&M that provide emergency vascular services and

neither meet the majority of the national guidelines.

• There is no 24/7 access to specialist vascular care
• There is an agreed network strategy across EKHUFT and MMFT
• It has been agreed that a single

vascular service will be delivered across K&M with a arterial centre on

• ne site
• National guidelines state that specialist doctors, nurses and therapists should

be available 24/7; none of the hospitals in east Kent achieve this.

• No hospital in east Kent thrombolyses all eligible stroke patients within the

national guideline recommended time of 60 minutes.

• Urgent need to consolidate services

to improve quality and reduce likelihood of excess mortality. Service Case for Change Implications

Cas ase for

• r Cha

hange of

• f the

the pri priorit itis ised ser servic ices for

• r Pha

hase 1 Con

• nsultatio

ion in n ea east Ken ent

SOURCE: Kent & Medway Case for Change, Carnall Farrar analysis

• Significant opportunities to improve

efficiency and quality by standardising planned care to best practice by consolidating elective inpatient orthopaedics. Elective Orthopaedics

• A rise in the elderly and obese population is driving an increase in demand
• Waiting lists for planned care are growing
• Pressure from emergency patients requiring admission is increasing the

number of on the day cancellations.

• Patient experience and outcomes could be improved
• Workforce constraints prevent the delivery of 7 day services and 24/7

consultant cover across most hospitals in east Kent.

• In some hospitals, senior doctors are not present at the weekend or are trying

to cover more than one clinical area at a time.

• Support services for discharge are also not available at the weekend.
• The configuration of acute medicine

sites should be optimised according to Keogh definitions to deliver more senior doctor cover.

• Across K&M, attendances to major ED departments have risen by 2.2% per

year over the last 3 years (twice the national average)

• Providers have some of the worst patient satisfaction scores in the country for

ED

• Performance on the 4 hour waiting target has deteriorated over the last 2
• years. On average 86% of people in K&M are discharged within 4 hours (target

= 95%).

• The configuration of acute medicine

sites should be optimised according to Keogh definitions. Acute medicine Emergency Departments Urgent care b a

77

CONFIDENTIAL

We have discussed Elective Orthopaedics with CCGs (September 2017) and they have agreed that the model of care can be taken forward through the hurdle criteria to the next stage and assessed against the evaluation criteria. A number of points have been raised and work has already commenced to address these. See appendix 2. The future elective model will be set within the context of the wider transformation programme underpinned by a focus on prevention and self-care and the benefit of a community-led musculoskeletal (MSK) pathway, which is part of the local care work

• stream. The Kent MSK strategy sets out an approach to reduce elective activity by 25%. These plans include:

– Developing a single point of access; – exploring the use of care coordinators; – to triage and signpost patients to the appropriate place for first time treatments; – recruiting and training Extended Scope Practitioners (ESP) to support local primary care teams in assessments and making referrals; – developing a workforce plan and provide tailored training to practitioners at an STP level to ensure sustainability in service provision; – providing treatment / surgery information for patients to understand their conditions and options and to manage their expectations; – to avoid last minute surgery cancellation; – share resources / facilities within the STP network e.g. group treatments / information sessions, etc; – to create productivity savings; and – map the distribution of resources and expertise in the STP e.g. GPs with specialist interest.

CCG Discussio ion

78

CONFIDENTIAL

The Trust has larger numbers of patients waiting longer, in pain, than ever before. In the last four years the elective orthopaedic waiting list has increased by 75%. Despite extra resources being provided this list continues to grow on a monthly basis. The number of patients waiting in excess of 35 weeks has grown by 50% in last two years. There is a range of guidance from the National Institute for Care and Health Excellence (NICE), the British Orthopaedics Association (BOA) and other advisory bodies, recommending the separation of elective and non-elective surgery and outlining the link between volume and outcomes. Similarly, the separation of pathways for emergency and elective surgery is supported by a number of bodies, including the Royal College of Surgeons. It is suggested that this separation can result in:

• earlier investigation;
• definitive treatment;
• better continuity of care;
• Reduction in hospital-acquired infections; and
• Reduction in length of stay (LoS)1.

South East Coast Clinical Senate – recommendations show that elective units undertaking more than 3,000 joint procedures would enable delivery of the standards and improvements to the service. In 2015/16, the Trust undertook 3,675 elective inpatient procedures and outsourced a further 743 elective inpatient procedures giving a total of 4,418

• procedures. Out of this, 3,060 procedures related to joint surgery (shoulder, knee, elbow, hip, etc).

National guidance, including the 5-year forward view, supports the segregation of elective and trauma services A cold elective inpatient elective orthopaedic centre would improve theatre productivity and utilisation. For example:

• South West London elective orthopaedic centre’s (SWLEOC) average theatre time is 24% shorter than the Trusts
• SWLEOC achieves 95% theatre utilisation (2008/09). EKHUFT is currently achieving 85%.
• National evidence indicates complications and the need for revisions would reduce.
• Earlier access to rehabilitation and specialist support services so rehabilitation services can be concentrated onto one site thus enabling the

drive towards a 7 day service.

Cas ase for

• r ch

change for

• r ele

electiv ive ort

• rthopaedic

ic sur surgic ical l ser servic ices

Source: 1 The reconfiguration of clinical services” (2014) The Kings Fund

79

CONFIDENTIAL The increasing demand for elective orthopaedic surgery in East Kent is being driven by a number of factors including:

• Increasing demographics driven demand:

➢ High elderly population in east Kent - over 60’s are +29% of the total population; and ➢ Thanet – over 68% of people in the district overweight or obese.

• Increasing demand for trauma services

➢ Elective theatre schedules frequently disrupted by trauma patients; ➢ Past three years has seen a fourfold increase in patients cancelled on day of operation: In January 2017, 31 last minute cancellations which was roughly the same as the whole of 2013; and ➢ Substantial evidence show that surgeons need to operate on a minimum number of patients per year to improve quality and patient outcomes.

Source of cancellation data: EKHUFT Theatreman system Source of Consultant-led Referral to Treatment Waiting Time Data : NHS England, Provider based, September 2014, 2015, 2016

Case ase for ch change for ele lective ort

• rthopaedic

ic su surgical se services

80

CONFIDENTIAL

Scope of

• f el

electiv ive ort

• rthopaedic

ic ser servic ices revi view and and rec econfig iguratio ion in n ea east t Ken ent

An Elective orthopaedic surgical service comprises of inpatient surgery, day case surgical activity and outpatients. Elective orthopaedic services discussed in this paper will only refer to inpatient services and not day case surgery

• r outpatient appointments as these services will continue to be delivered from their current locations.

The scope of this review is focused on inpatient activity for the following reasons:

• Day case activity is currently under taken on all 3 of the acute sites in east Kent and is not reliant on bed

availability as it is delivered from dedicated day case units.

• A reduction in sites offering day surgery would require further capital expenditure on new theatres to be

built.

• Continuing to provide day case activity as locally as is possible would be advantageous to the local

communities and in line with the 5 year forward view. Elective orthopaedic delivery service models discussed in this paper will refer only to inpatient services and not day case surgery or outpatient appointments as these services will continue to be delivered from their current locations.

81

CONFIDENTIAL

Urgent care services Background

Con Conten ents

Appendix Applying the hurdle criteria on urgent care options Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Single site developer options at K&CH Agreed K&M Fixed Point Criteria

82

CONFIDENTIAL

A set t of

• f hurdle crit

criteria ia have e bee een agr greed by th the e Clin Clinical l Boa Board and Fin inance e wor

• rking Group

Is the potential configuration

• ption clinically

sustainable? Is the potential configuration

• ption financially

sustainable?

• Does it deliver key quality standards?
• Does it address any co-dependencies?
• Will the workforce be available to deliver it?
• Will there be sufficient throughput or catchment population to maintain skills and deliver

services cost effective? Is the potential configuration

• ption

implementable?

• Must not increase the ‘do nothing’ financial baseline
• Will the option deliver financial and clinical sustainability within a medium-term

timeframe by 20/21? This statement is based upon a system wide view, this may mean that some organisations have a net negative financial impact as well as some have a net positive impact. Is the potential configuration

• ption accessible?
• Does it implement the outcome of other recent consultations or designation processes?

Is the potential configuration

• ption a strategic

fit?

• Is the maximum travel time (by car) an average of one hour or less?

83

CONFIDENTIAL

Develo lopin ing the the op

• ptio

ions s for

• r elec

electiv ive ort

• rthopaedic

ic se servic ices s acr cross s ea east Ken ent

WHH K&C QEQM

In east Kent, there is one trust (east Kent Hospitals Foundation Trust - EKHUFT) providing in- patient elective orthopaedic services across two main acute sites (William Harvey Hospital – WHH and Queen Elizabeth the Queen Mother Hospital). This service could be provided on:

• 3 sites
• 2 sites
• 1 site
• 0 sites

Applying the hurdle criteria to assess the options for the identified services will result in a medium list of potential viable

• ptions for evaluation in further

detail.

84

CONFIDENTIAL

Note: Day case include some non-elective activity Note: Source: Provider data returns, Elective orthopedics activity, FY2015-16 Note: source South East Coast Clinical Senate review of clinical models

H H H H H H H

IP 2.072 DC 3,244

IP = In patient DC = Day case

IP 2,072 DC 3,244 William Harvey Hospital (Ashford) IP 1,528 DC 1,392 IP 75 DC 1,571 Queen Elizabeth the Queen Mother Hospital Kent and Canterbury Hospital

• The South East Coast

Clinical Senate reflected that large units undertaking 3,000 or more joint procedures would enable delivery of the standards/improvements

• In 2015/16, the Trust

undertook 3,675 elective inpatient procedures and

• utsourced a further 743

elective inpatient procedures giving a total

• f 4,418 procedures. Out
• f this, 3,060 procedures

related to joint surgery (shoulder, knee, elbow, hip, etc).

In 2015/16 the there e wer ere e 9,882 elec elective e (i (inpatie ient and day case se) ort

• rthopaedic

ic proc

• cedures

s under ertaken in ea east Ken ent

85

CONFIDENTIAL

The e foll

• llowing sp

speci ecific icatio ion for

• r an elec

elective e cen centre has s bee een agr gree eed

Anaesthetics Outpatient services Non-complex inpatient surgery (85%) Non-complex day case surgery (99%) Support services (see key)

Key

Co-location

• n same site

Support services

▪

Co-located

–

Physiotherapy

–

Occupational Therapy

–

Emergency imaging and reporting

*The presence of L2 critical care will mean a more complex case mix can be seen. Source: Carnall Farrar analysis based on collected clinical opinion

Simple diagnostics Specialised emergency surgical opinion Specialist imaging Acute medical opinion and assessment Critical care Acute medical intervention Lab based diagnostics Networked services

86

CONFIDENTIAL

K&C WHH QEQM Site Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 Option 8 MEC MEC EC EC

ICH ICH

ME EC

ICH

MEC EC EC MEC MEC EC

ICH GFS

MEC MEC

MedEC MedEC MedEC

Elective inpatient orthopaedic centre

Lon Long list of

• f op
• ptio

ions s for

• r elec

electiv ive ort

• rthopaedic

ic se servic ices s in ea east Ken ent

None – no centre Single site for Kent & Medway

87

CONFIDENTIAL

As Asse sess ssin ing the the impact of

• f hurdle

le crit criteria ia

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

88

CONFIDENTIAL

Inp Inpatient el electiv ive orth

• rthopaedic volu
• lumes

s sugg suggest that an an el elective orth

• rthopaedic ser

service is s req equired an and sus sustain inable le in eas east t Kent

Note: Day case include some non-elective activity Source: Provider data returns, Elective orthopedics activity, FY2015-16; 1) http://www.eoc.nhs.uk/

• SE Coast Clinical Senate has stated the evidence suggests that elective units undertaking more

than 3,000 joint procedures a year would enable the delivery of higher standards of care and improvements for patients and the efficiency of the service.

• EKHUFT provides elective orthopaedic services to 695,000 population in east Kent.
• In 2015/16, the Trust undertook 3,675 elective inpatient procedures and outsourced a further

743 elective inpatient procedures giving a total of 4,418 procedures. One of the largest providers in the country currently delivers 5,300 elective inpatient procedures

• Out of this, 3,060 procedures related to joint surgery (shoulder, knee, elbow, hip, etc).

Therefore, the option not to have an elective orthopaedic service in east Kent has been discounted Is s the the op

• ptio

ion cl clin inic icall lly su sustainable le?

89

CONFIDENTIAL

• If there was a single elective orthopaedic centre in Kent & Medway it would undertake 9,000 plus in-patient

procedures per year.

• This would make it almost twice the size of the current largest elective orthopaedic centre in the country
• It would require a minimum of 12 operating theatres
• It would require 109 in-patient beds
• If the centre wasn’t in east Kent approximately 45,000 of the east Kent population would be outside of the 60

minute travel time

• This is not considered to be implementable within the agreed time-line

Having a single elective orthopaedic centre for Kent & Medway and not having a service in east Kent would not be implementable due to the size of the centre and the necessary clinical infrastructure to support the activity

• N.B. Kent Institute of Medicine and Surgery (KIMS) currently has 5 theatres and 72 in-patient beds

Is s the the op

• ptio

ion cl clin inic icall lly su sustainable le? Therefore, the option to have a single elective orthopaedic service for Kent and Medway has been discounted

90

CONFIDENTIAL

Source: British Journal of Surgery, A systematic review of the impact of volume of surgery and specialisation on patient outcomes, 2007; 94; 145–161

Furt rther evid idence suggests in incr creased volu

• lume and speci

ciali lisation can im improve ou

• utcomes in

in speci ecialist surgery ry, str trength thening th the e case e for

• r not
• t in

increasing th the e number of

• f sit

ites es

Positive volume/outcome relationship found, % Specialty Overall Mortality LOS Complication rate

• No. of studies

Hospital volume1 All specialties 74 76 79 62 127 Surgeon volume1 All specialties 74 71 78 81 58 4.7 4.4 4.2 4.2 4.2 0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 1.0 2.0 3.0 4.0 5.0 Mean LoS (days) 5 4 3 2 1 Least specialised Most specialised

• A review of 127 studies found strong evidence for a volume/outcomes relationship in specialist surgery
• There is a correlation between higher volume of operations the hospital undertakes and better outcomes for the patient.
• There is a correlation between the number of procedures the surgeon undertakes and the reduction in clinical complications and therefore

improved outcomes.

• In orthopaedics, increased specialisation improves outcomes and reduces length of stay (LoS)
• LoS and patient outcomes following total hip /knee replacements for 3,818 US hospitals, stratified into quintiles by degree of specialisation
• The graph shows that the more specialised the hospital the lower the LoS and the greater the reduction in complications

90 day composite outcome

91

CONFIDENTIAL

Is s the the op

• ptio

ion cl clin inic icall lly su sustainable le?

1) Is it clinically sustainable? Criteria Implication Possible configurations

▪ In-patient elective orthopaedic

services will be delivered from either 1, 2 or 3 sites in east Kent

▪ Single site for Kent and Medway has

been discounted Any 1, 2 or 3 site option for east Kent Is it clinically sustainable?

RECOMMENDATIONS The analysis shows that:

• In-patient elective orthopaedic services are currently provided at two main acute sites in east Kent (WHH and QEQM)
• There are currently 4,741 inpatient elective procedures being undertaken in east Kent; the largest orthopaedic centres in

the country deliver 5,300 procedures

• The current volume of in-patient elective orthopaedic activity undertaken strongly supports an elective orthopaedic

service is required in east Kent. This is supported by the South East Coast Clinical Senate recommendations.

• A single elective orthopaedic centre in Kent & Medway it would undertake 9,000 plus in-patient procedures per year. This

would make it almost twice the size of the current largest elective orthopaedic centre in the country. It would require large numbers of beds and theatres to be invested in and would mean that approximately 45,000 of east Kent’s population would be outside of the 60 minute travel time. CONSEQUENCES OF THE RECOMMENDATIONS Only options where in-patient elective orthopaedic services are delivered from any one, two or three sites in east Kent go forward to be tested against the next hurdle criterion.

92

CONFIDENTIAL

K&C WHH QEQM Site Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 MEC MEC EC EC

ICH ICH

ME EC

ICH

MEC EC EC MEC MEC EC

ICH GFS

MEC MEC MEC

MedEC MedEC MedEC

Rem emain inin ing list of

• f op
• ptio

ions s for

• r elec

electiv ive ort

• rthopaed

edic se servic ices s foll

• llowing appli

lication again inst the the cl clin inic ical su sustain inabil ility cri criterio ion

None – no centre Elective inpatient orthopaedic centre Option 8

93

CONFIDENTIAL

As Asse sess ssin ing the the impact of

• f hurdle

le crit criteria ia

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

94

CONFIDENTIAL

• There is a requirement for 43 elective inpatient orthopaedic beds in east Kent so the

number of beds that need to be moved under any option is relatively small

• Elective inpatient orthopaedics requires some other clinical services which are all

available at all the sites so no other services would need to be moved

• If elective orthopaedic beds were to be centralised onto one site alongside all other non-

elective surgical activity there would be a requirement for additional bed and theatre capacity

What opti tions are im imple lementable le by 20/21?

Source: Provider returns (2015), Carnall Farrar analysis (2017)

Therefore, all remaining options are considered implementable

95

CONFIDENTIAL

Is s the the op

• ptio

ion imple lemen entable le?

RECOMMENDATIONS The analysis shows that:

• The number of beds required for elective orthopaedics is relatively small compared to the total bed base
• All existing acute sites deliver the required clinical co-dependencies

CONSEQUENCES OF THE RECOMMENDATIONS 1. Only options where in-patient elective orthopaedic services are delivered from any one, two or three sites in east Kent go forward to be tested against the next hurdle criterion.

2) Is it implementable?

2) Is it implement able?

Criteria Implication Possible configurations

▪ In-patient elective orthopaedic

services will be delivered from either 1, 2 or 3 sites in east Kent Any 1, 2 or 3 site options for east Kent

96

CONFIDENTIAL

K&C WHH QEQM Site Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 MEC MEC EC EC

ICH ICH

ME EC

ICH

MEC EC EC MEC MEC EC

ICH GFS

MEC MEC MEC

MedEC MedEC MedEC

Rem emain inin ing list of

• f op
• ptio

ions s for

• r elec

electiv ive ort

• rthopaed

edic se servic ices s foll

• llowing appli

lication again inst the the imple lementable le cri criterio ion

None – no centre Elective inpatient orthopaedic centre Option 8

97

CONFIDENTIAL

As Asse sess ssin ing the the impact of

• f hurdle

le crit criteria ia

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

98

CONFIDENTIAL

A single site option on any one of east Kent’s current hospital sites allows all patients to access a site (either in K&M or periphery) within 60 minutes

*Impacted population means that only the population whose closest service location in terms of travel time changed is analysed, the maximum this is taken as an average of the 5 longest minimum travel times SOURCE: Base map; Carnall Farrar Analysis. Travel times,, by car

If the in patient elective orthopaedics were only offered at WHH If the in patient elective orthopaedics were only offered at QEQM If the in patient elective orthopaedics were only offered at K&C

Site Configuration Option Maximum travel time for impacted population*

NOTE: This analysis assumes that for each option patients will travel to the next closest site in terms

• f travel time that is
• ffering a service – this

includes sites outside of East Kent

Peak

59 mins 50 mins 43 mins

Doe

• es the

the op

• ptio

ion deliv eliver er acces ccessib ible le se servic ices? s? All patients live within 60 minutes travel time of an elective orthopaedic service

99

CONFIDENTIAL

3) Is it accessible?

Criteria Implication Possible configurations Is it clinically sustainable?

RECOMMENDATIONS

The analysis shows that:

• In any option 100% of the impacted population can access this service within 60 minutes

CONSEQUENCES OF THE RECOMMENDATIONS

1. Only options where in-patient elective orthopaedic services are delivered from any one, two or three sites in east Kent go forward to be tested against the next hurdle criterion.

▪ In-patient elective orthopaedic

services will be delivered from either 1, 2 or 3 sites for east Kent Any 1, 2 or 3 site options for east Kent

Doe

• es the

the op

• ptio

ion deliv eliver er acces ccessib ible le se servic ices? s?

100

CONFIDENTIAL

K&C WHH QEQM Site Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 MEC MEC EC EC

ICH ICH

ME EC

ICH

MEC EC EC MEC MEC EC

ICH GFS

MEC MEC MEC

MedEC MedEC MedEC

Rem emain inin ing list of

• f op
• ptio

ions s for

• r elec

electiv ive ort

• rthopaed

edic se servic ices s foll

• llowing appli

lication again inst the the acce ccess ssib ible le cri criterio ion

None – no centre Elective inpatient orthopaedic centre Option 8

101

CONFIDENTIAL

As Asse sess ssin ing the the impact of

• f hurdle

le crit criteria ia

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

102

CONFIDENTIAL

• Future options for changes to services will be aligned with existing commitments, in particular to ensure that they do not

challenge or unpick past decisions around configuration of services.

• Existing commitments have been defined as:
• Designation processes: Ensure that the options do not go against any designation for service provision which has gone

through an agreed process

• Consultations: Ensure that the options taken forward address the reasons underpinning previous consultation,

predominantly workforce and Royal College driven.

Do Does th the op

• pti

tion have str trategic fit fit with ith oth

• ther recent

t con

• nsultations or
• r design

ignation processes?

• There are no existing designation for elective inpatient orthopaedic surgical services in east Kent
• Reconfiguration in 2003 reduced the number of sites orthopaedic services were delivered from three to two to ensure

compliant doctors’ rotas and safe numbers to meet the standards required to support sub-specialisation required by the Royal College.

Previous consultations have reduced the number of sites elective orthopaedic services are offered on from three to two

103

CONFIDENTIAL

4) Is it a strategic fit? Criteria Implication Possible configurations

Is it clinically sustainable?

RECOMMENDATIONS The analysis shows that no previous designations affect the remaining options However, previous consultations have reduced the number of sites where inpatient elective orthopaedic services are provided from three sites to two. CONSEQUENCES OF THE RECOMMENDATIONS Therefore only one and two site options will be taken forward for further analysis

▪ In-patient elective orthopaedic services

will be delivered from either 1 or 2 sites in east Kent

Do Does es th the e op

• pti

tion have e str trateg egic fit fit with ith oth

• ther recen

ent t con

• nsultations or
• r des

esign ignation processes?

No more than 2 in-patient elective orthopaedic centres located on any site in east Kent.

104

CONFIDENTIAL

K&C WHH QEQM Site Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 MEC MEC EC EC

ICH ICH

ME EC

ICH

MEC EC EC MEC MEC EC

ICH GFS

MEC MEC MEC

MedEC MedEC MedEC

Rem emain inin ing list of

• f op
• ptio

ions s for

• r elec

electiv ive ort

• rthopaed

edic se servic ices s foll

• llowing appli

lication again inst the the str trategic fit fit cri criterio ion

None – no centre Elective inpatient orthopaedic centre

105

CONFIDENTIAL

As Asse sess ssin ing the the impact of

• f hurdle

le crit criteria ia

Each of the hurdle criteria is examined in sequence to assess the impact on the future options Is the option financially sustainable over the medium to long term? Is the option clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option deliver accessible services? Does the option have strategic fit with other recent consultations or designation processes?

106

CONFIDENTIAL

WHH QEQM K+C Total Estimated beds (2015/16) 21 18 39 Required capacity (2020/21) – after local care interventions 23 20 43

It t has s bee een calculated ed tha that the there wil ill l be e a req equir irement of

• f 43

43 in patie tient elec elective ort

• rthopaedic

ic bed eds s by 2020/2 /21 aft fter er loc

• cal

l care interventions

In patient elective orthopaedic bed requirements in east Kent in 20/21

Note: Assumed occupancy rates: 91%. ‘Sustainable occupancy’ lever estimates the impact of reducing acute bed occupancy levels to 85% across the Kent and Medway system. Source: east Kent provider length of stay LSOA data; NHSE KH03 occupancy data, 2015/16; K&C population growth estimates; Carnall Farrar analysis

Is s the the op

• ptio

ion fi financiall lly su sustainable le over er the the med ediu ium to

• lon
• ng

g ter erm?

107

CONFIDENTIAL The future potential bed capacity below, has been calculated based on the bed numbers at WHH following inclusion of all the elective orthopaedic inpatient beds, based on the east Kent urgent care configuration of WHH as an MEC, QEQM as an EC and K&C ICH/UCC. Using this model the number of beds required would be:

• a shortfall at the WHH of 136 beds. If the elective orthopaedic beds from QEQMH were then also to moved to WHH to create

a centralised elective orthopaedic centre at WHH a further 20 beds would need to be built (a deficit of 156).

• In addition, 4 new laminar flow theatres would need to be built at the WHH to deliver this activity
• The cost of a 20 bed ward is c.£7.3m and the cost of 4 laminar flow theatres is c.£5m. This would give a total of c£12.3m,

assuming new build.

• Further service moves could also be made to the WHH site as part of the K&M stroke work and also as part of the work on

vascular services. If the move of HASU / ASU beds was also made to the WHH site it would require an 35 beds. An additional 3 theatres and 24 beds would also be required for vascular.

• By co-locating these services alone, you take the WHH to a bed deficit of 215 beds and 7 theatres.
• Importantly, there is no vacant capacity at the WHH to utilise, so these would be need to be new builds. In addition, given the

theatres would need ancillary space, you are really looking at a new stand alone elective orthopaedic unit.

• A suitable location would have to be identified which will be difficult from a co-location perspective and may involve building
• n a car park and linking to the main site (including re-provision of car park costs).
• The cost of a new elective centre on the WHH site could cost as much as c£27m.

Source: SKHUFT high level capital costs; east Kent provider length of stay LSOA data; NHSE KH03 occupancy data, 2015/16; K&C population growth estimates; Carnall Farrar analysis.

A A sin single le elec electiv ive ort

• rthopaedic

ic cen centre at t the the WHH

108

CONFIDENTIAL

Is Is the the op

• pti

tion fi financially ly sus sustain inable le?

RECOMMENDATIONS The analysis shows that:

• The total number of elective inpatient orthopaedic beds required in east Kent by 2020/21 is 43.
• Under all options there is not enough space to move these beds onto the WHH site without realistically requiring c£27m

investment in new build.

• Two inpatient elective orthopaedic units could be accommodated on any two site configuration

CONSEQUENCES OF THE RECOMMENDATIONS 1. All two-site options will continue to be considered. 2. Only one-site options at QEQM and K&C will be considered.

5) Is it financially sustainable? No more than 2 in-patient elective

• rthopaedic centres located on any
• site. All single site configurations,

with the exception of a WHH single site configuration will be taken forward. 5) Is it financially sustainable?

▪ In-patient elective orthopaedic services will be

delivered from either one or two existing sites but, in a single site configuration, not from WHH.

109

CONFIDENTIAL

K&C WHH QEQM Site Option 2 Option 4 Option 5 Option 6 Option 7 MEC MEC EC EC

ICH ICH

ME EC

ICH

MEC EC EC MEC MEC EC

ICH GFS

MEC MEC MEC

MedEC MedEC MedEC

None – no centre Elective inpatient orthopaedic centre

List of

• f op
• ptio

ions for

• r el

electiv ive orth

• rthopaedic ser

servic ices foll llowin ing app applic ication ag again inst the the fi financial sus sustain inabil ility ty crit criterio ion

110

CONFIDENTIAL

Criteria Implication 4) Is the option a strategic fit? 5) Is the

• ption

financially sustainable? 3) Is the option accessible?

• In-patient elective orthopaedic services will be delivered from either 1, 2 or 3 sites in

east Kent

• Single site for Kent and Medway has been discounted

▪

In-patient elective orthopaedic services will be delivered from either 1, 2 or 3 sites for east Kent

Sum ummary ry of

• f the

the ap appli licatio ion of

• f Hur

urdle le Crit riteria ia ag again inst EK EK el electiv ive ort

• rthopaedics op
• ptio

ions

2) Is the option Implementable? Possible configurations for elective orthopaedic centres 1) Is the option clinically sustainable?

▪

In-patient elective orthopaedic services will be delivered from either 1 or 2 sites in east Kent

▪

In-patient elective orthopaedic services will be delivered from either 1, 2 or 3 sites in east Kent

• In-patient elective orthopaedic services will be delivered from either one or two existing

sites but, in a single site configuration, not from WHH Any 1,2 or 3 sites option for east Kent Any 1,2 or 3 sites option for east Kent Any 1,2 or 3 sites option for east Kent No more than 2 in-patient elective

• rthopaedic centres located on any

site in east Kent. No more than 2 in-patient elective

• rthopaedic centres located on any
• site. All single site configurations,

with the exception of a WHH single site configuration, will be taken forward.

111

CONFIDENTIAL

In Intr troductio ion of f a sin single le sit site develo loper optio tion at t K& K&CH CH

Amending the hurdle criteria or the process that has been used to apply them is not appropriate and would undermine the work undertaken to date. Whilst the proposal sits outside of the process undertaken to date, due to the materiality of the development and in recognition

• f the feedback received through engagement activities, it would be unreasonable not to consider the developer’s proposal.

The proposal from the developer will be considered as an additional option and will be taken into account alongside the urgent care options that comes out of the application of the hurdle criteria.

Therefore it is proposed that option 3, to have a single elective orthopaedic centre at WHH, is re-introduced.

Implications for orthopaedic services:

• A single MEC with specialist services at K&CH and the provision of two supporting sites (IHC / UCC) would free up significant

estate at both QE and WH. It would also mean that a single elective orthopaedic centre at the WHH could be delivered in current estate.

112

CONFIDENTIAL

K&C WHH QEQM Site Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 MEC MEC EC EC

ICH ICH

ME EC

ICH

MEC EC EC MEC MEC EC

ICH GFS

MEC MEC

MedEC MedEC MedEC

None – no centre Elective inpatient orthopaedic centre

Fin Final l med ediu ium list of

• f op
• pti

tions for

• r ele

electiv ive ort

• rtho

hopaedic ic ser servic ices

113

CONFIDENTIAL

Urgent care services Background

Con

• ntents

Appendix Applying the hurdle criteria on urgent care options Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Single site developer options at K&CH Agreed K&M Fixed Point Criteria

114

CONFIDENTIAL

APPENDIX 1 Ele lectiv ive Ort rthopaedics

115

CONFIDENTIAL

De Detail iled capit ital l brea eakdown of

• f build

ildin ing a new hos

• spital

l on

• n a gr

greenfiel eld sit ite e or

• r sin

ingle gle sit ite e op

• pti

tion

• n
• n a cu

current acu cute sit ite

SOURCE: EK Clinical Strategy Capital Cost Summary 14 Nov 2017 completed by The Cot 16 Old Green Road Margate Kent CT9 3LZ

116

CONFIDENTIAL

SOURCE: EK Clinical Strategy Capital Cost Summary Nov 2017 completed by GPM Partnership 5/7 Ozengell Place, Eurokent Business Park Ramsgate Kent CT12 6PB

De Detail iled capit ital l brea eakdown of

• f removing all

ll ser ervices es fr from on

• ne

e sit ite e and rep eproducing g th them em on

• nto

th the e oth

• ther tw

two

• sit

ites es

117

CONFIDENTIAL

Sout

• uth Wes

est t Lon

• ndon El

Electiv ive Orth rthopaedic ic Cen entre is s a a goo

• od example of
• f a

a de dedic icated ele electiv ive cen centre

Model

• SWLEOC utilises the latest techniques and technology to provide high quality care, minimising infection and supporting patients return

to normal in the shortest and safest way1

• Innovations such as new wound catheter technique allows faster mobilisation, recovery and reduced length of stay for patients1
• The Centre is run through a partnership model across the four local acute trusts1
• The trusts provide a team of 28 consultant orthopaedic surgeons who deliver care in collaboration with the Centre’s multidisciplinary

teams that allow streamlining patient pathways1

• Stand alone unit on Epsom Hospital site with ‘ring-fenced’ theatres, beds and staff for planned orthopaedic surgery4

Outcomes

• LOS for knee replacement around 4.78 days, compared to a London average of 8.05 days2
• Consistently achieves operational targets, including length of stay and minimal infection rates3 as well as high inpatient satisfaction

scores (below)

• 97% of patients would be likely to recommend SWLEOC wards to friends and family if they needed similar care or treatment3
• Over 95% theatre utilisation in 2008/20094
• Surplus of £0.5m on a £27m turnover (1.8%)4
• Performed over 5,200 procedures in 2015/16, 3,000 of these joint replacements
• SWLEOC provides a centre of excellence for 1.5 million people in South West London
• Largest state-of-the-art treatment centre for orthopaedic surgery in the UK
• Purpose built

Background

1 The Trust Special Administrator draft report (2006) 2 Kingston Hospital Annual Report (2010-11) 3 EOC newsletter (2013) 4 EOC annual report (2009) http://www.eoc.nhs.uk/

0% 25% 50% 75% 100% Privacy and dignity received whilst being examined or treated Pain control received whilst at EOC If prescribed new medications, satisfaction with information about them Involvement in decisions about treatment and care Delay on day of discharge

118

CONFIDENTIAL

APPENDIX 2 Sum ummary ry of

• f CCG Discussions; key fee

eedback, pr prog

• gress so

so far ar and and ne next xt step

Potential for

• r neg

negative impacts of

• f pr

proposed ch changes on

• n pa

patients

Presentation of

• f information an

and pr procedural l iss ssues

Model of

• f Car

Care