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

CONFIDENTIAL Th The e Keo eogh rep eport rt (2 (2014) ) se sets ou out t a a mod odel l for or dif different t ty type pes of of cen centres tha that can provid pr ide ur urgent t and and em emer ergency care What Services offered • • Specialised centres co-locating tertiary/complex Neurosurgery, Cardiothoracic surgery Major trauma • services on a 24x7 basis Full range of emergency surgery and acute medicine centre • • Serving population of at least 2 -3million Full range of support services, ITU etc • Hyper-acute cardiac, stroke , vascular services Major • • Larger units, capable of assessing and initiating Trauma unit Emergency • treatment for all patients and providing a range of Level 3 ICU Centre with • specialist hyper-acute services Moving towards 24x7 consultant delivered A&E, emergency specialist • Serving population of ~ 1-1.5m surgery, acute medicine, inpatient paediatrics services • Full obstetrics and level 3 NICU • • Larger units, capable of assessing and initiating Moving towards 24x7 consultant delivered A&E, Emergency treatment for the overwhelming majority of emergency surgery, acute medicine • Centre patients but without all hyper-acute services Level 3 ICU • • Serving population of ~ 500-700K Inpatient paediatrics and obstetrics with level 2/3 NICU • • Assessing and initiating treatment for majority of Consultant led A&E • Medical patients Acute medicine and critical care/HDU • • Emergency Acute medical inpatient care with intensive Access to surgical opinion via network • care/HDU back up Possibly paediatrics assessment unit and possibly Centre • Serving population of ~ 250-300K midwife-led obstetrics • GP-led urgent care incorporating out of hours GP services • Assessing and initiating treatment for large • Integrated Step up/step down beds possibly with 48 hour proportion of patients assessment unit care hub with • Integrated outpatient, primary, community and • emergency Outpatients and diagnostics social care hub • care* Possibly midwife-led obstetrics • Serving population of ~ 100-250K • • Immediate urgent care As above but no beds • Urgent care Integrated outpatient, primary, community and centre* social care hub • Serving population of ~ 50-100K 11 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

CONFIDENTIAL Th The e thr three ty type pes of of Em Emer ergency ce centr tre laid id out out in n the the Keo eogh rep eport rt ar are sub subsets of of ea each ot other: 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 A MEC will have everything in an EC and MedEC, plus: • Vascular services • Trauma unit • Level 3 Intensive Care Unit (ICU) Major Emergency Centre • Moving towards 24x7 consultant delivered A&E, Major Emergency Centre with specialist services emergency surgery, acute medicine, inpatient with specialist services 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 Centre emergency surgery, acute medicine Emergency Centre • Level 3 ICU • Inpatient paediatrics and obstetrics with level 2/3 NICU A MedEC will have: Medical Emergency Medical Emergency • Consultant led A&E Centre • Acute medicine and critical care/High Centre Dependency Unit (HDU) • Access to surgical opinion via network • Possibly paediatrics assessment unit and possibly midwife-led obstetrics 12

CONFIDENTIAL Non on-acute ur urgent t car are op opti tions – In Integrated Car are Hosp ospital and and/or r Urgen ent t Car are Cen entre An ICH will have • GP led urgent care 24/7 Integrated Care Hospital • Step up/down beds • Out patients and diagnostics An UCC will have • As above but with no beds Urgent Care Centre Com ommis issio ioners will ill wor ork tog ogether to o loo look at t the these op optio ions an and the the evalu luatio ion cri criteria ia pa pack will ll pr prog ogress the them whe here app appli licable 13

CONFIDENTIAL The The fol ollo lowin ing spe specif ific icatio ion for or 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 on the the Keo eogh mod odel l an and SEC Clin inic ical l Sen enate ser servic ice co-dependencies Key Emergency Department Acute cardiology Plastic surgery Anaesthetics (unselected) Additional services that Critical care (L1, L2 & 3) General surgery Acute oncology Co-location on should in-reach if Acute and general same site not based on- medicine (inc. AMU) Clinical microbiology Acute gynaecology Palliative care site Liaison psychiatry Elderly medicine Trauma Rheumatology Specialist Diagnostics inc. MRI Respiratory medicine Orthopaedics* services Dermatology Urgent haematology Medical gastroenterology Urology* Maxillo-facial surgery Support services Support services (see key) ENT* Urgent GI endoscopy ▪ Co-located Neurology – Social care Nephrology (not including Trauma unit Interventional cardiology – Physiotherapy • dialysis) Acute paeds (PC/i) Burns – Occupational Therapy – Lab based diagnostics Vascular surgery (spoke) Consultant-led obstetrics Acute stroke unit – Interventional radiology Emergency imaging and Inpatient rehabilitation reporting Vascular surgery (hub) Acute paediatrics* ▪ Ideally co-located Diabetes & endocrinology • HASU Hyper acute stroke unit – Speech and language • Interventional radiology therapy Ophthalmology – 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 14

CONFIDENTIAL Th The e fol ollo lowin ing spe specif ific icatio ion for or an an Em Emer ergency Cen entre has has be been ag agreed bas based on on the the Keo eogh mod odel an and SEC Clin linical l Sen enate ser service co-dependencie ies Key Emergency Department Acute cardiology Anaesthetics Plastic surgery (unselected) Additional services that Critical care (L1, L2 & 3) General surgery Acute oncology Co-location on should in-reach if Acute and general same site not based on- medicine (inc. AMU) Clinical microbiology Acute gynaecology Palliative care site Liaison psychiatry Elderly medicine Trauma Rheumatology Diagnostics inc. MRI Networked Respiratory medicine Orthopaedics* Dermatology Urgent haematology Urology* Medical gastroenterology Maxillo-facial surgery Support services Support services (see key) ENT* Urgent GI endoscopy ▪ Co-located Neurology – Social care Nephrology (not including Trauma unit Interventional cardiology – Physiotherapy • dialysis) Acute paeds (PC/i) Burns – Occupational Therapy – Lab based diagnostics Vascular surgery (spoke) Consultant-led obstetrics Acute stroke unit – Interventional radiology Emergency imaging and • Inpatient rehabilitation reporting Vascular surgery (hub) Acute paediatrics* ▪ Ideally co-located Diabetes & endocrinology • HASU Hyper acute stroke unit – Speech and language • Interventional radiology therapy Ophthalmology – 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 15

CONFIDENTIAL The Th e fol ollo lowin ing spe specif ific icatio ion for or an an Med edic ical Em Emer ergency Cen entre has has be been ag agreed bas based on on the Keo the eogh mode odel l and and SEC Clin inic ical l Sen enate ser servic ice co-dependencies Key Emergency department Critical Care (L2 &L3) Urgent haematology (selective) Additional services that Anaesthetics Liaison psychiatry Co-location on should in-reach if Acute and general same site not based on- medicine (inc. AMU) Diagnostics inc. MRI Support services (see key) site Elderly medicine Acute oncology Clinical microbiology Could be co- Respiratory medicine located on site Palliative care Diabetes & endocrinology Medical gastroenterology Rheumatology Dermatology Support services Urgent GI endoscopy Urology Nephrology (not including ▪ Ideally co-located dialysis) – Acute cardiology Social care Interventional radiology – Physiotherapy Neurology – Occupational Therapy General (adult) surgery Consultant-led obstetrics – Lab based diagnostics • Neonatology Ophthalmology – Emergency imaging and Urgent care centre reporting Paediatric assessment unit Maxillo-facial surgery – Speech and language Fracture clinic therapy Rehabilitation Vascular surgery (spoke) – Dietetics Dialysis 16 Source: [The Clinical Co-Dependencies of Acute Hospital Services: A Clinical Senate Review December 2014], Carnall Farrar analysis

CONFIDENTIAL Lon ong list t of of op optio ions for or ur urgent car are ser servic ices Option 2 Option 1 Option 3 Option 9 Option 4 Option 5 Option 6 Option 8 Site Option 7 MedEC UCC MedEC UCC MEC MEC K&C EC ICH EC ICH MedEC MedEC UCC UCC WHH MEC MEC ICH EC EC ICH MedEC MedEC UCC UCC MEC MEC QEQM ICH ICH EC EC Green GFS MEC field site Single site on existing MEC site MEC Closing a site EC Emergency centre None – no centre Urgent care centre Integrated care hospital Medical Emergency Centre Major emergency centre with specialist services Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it 17

CONFIDENTIAL Ass ssessing the the impa pact of of 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 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? Is the option financially sustainable over the medium to long term? 18

CONFIDENTIAL Ana naly lysis is of of cli clinic ical l sus sustainabil ilit ity and and via viabil ilit ity has has focussed on on tw two o que questio ions • Services must treat a large enough volume of patients for staff to retain their skills and for services to be 1 cost effective. Is there sufficient catchment / • Where activity is low, it may be sensible to consolidate services and concentrate expertise. This is the throughput? model of care generally applied to more specialist services, which provide centralised care across a larger population. • There are a variety of quality standards that providers should meet which include staffing levels, access to 2 support services and timing of treatment. • It is difficult for small services to meet quality standards, often because of the lack of sufficient workforce Do the services and access to specialist equipment. deliver to standards, and is • There are minimum staffing requirements that need to be met by services to deliver quality standards and the workforce meet policy initiatives such as 7-day working. available to deliver it? • There are shortages in some staff groups and staff cannot easily be recruited. 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 19

CONFIDENTIAL In 2015/1 In /16 ea east Ken ent t ha have a a tot otal l pop populatio ion of of 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 Keogh recommends a catchment population of: 1. 1 to 1.5 million for a Major Emergency Centre Thanet CCG with specialist services 2. 500 to 700K for an Emergency Centre 145 Canterbury & 3. 250 to 300k for a MedEC Coastal CCG CCG 209 The 15/16 projected catchment population suggests that east Kent can sustain: Ashford CCG • no more than 1 Major Emergency Centres with 131 specialist services (pPCI serves whole of K&M, serving South Kent 210 a population of 1.2million) Coast CCG • 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 Population 20/21 Centres (thousands) Note: Includes just east Kent catchment population. Maternity and paediatrics not included. Source: 1 EK Case for Change 2016 20 Source: Sir Bruce Keogh, Transforming Urgent and Emergency care services in England, End of Phase 1 Report, 2014

CONFIDENTIAL Is Is the the op opti tion cli clinic icall lly sus sustain inable le over r the the med ediu ium to o lon ong term erm? 1. One Major Emergency Centre with specialist services based on the catchment size of 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 21

CONFIDENTIAL A num number r of of 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 Dartford & Tunbridge Service Medway Maidstone WHH K&C QEQM Catchment Gravesham Wells 24 hours primary ✓ percutaneous coronary x x x x x x 1.7m intervention (pPCI) Urgent maxillo-facial ✓ x x x x x x 990k surgery and oncology ✓ Renal inpatients x x x x x x 990k No arterial ✓ ✓ 710k 1 Vascular minor x x x work Substantial numbers of people would travel over 2 hours for specialist services if they were not offered in east Kent, suggesting a MEC with specialist services is required 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 22

CONFIDENTIAL Th The e volu olume of of majo ajor ED ED atten endances sug suggests the there is s suf suffic icient thr throughput for or tw two o Emer ergency Cen entres, an and the therefore the there cou ould be be on one or or tw two o Emer ergency Cen entr tre si sites ED Site Majors 1 QEQM K&C 21,946 42k QEQM 42,304 K&C 22k 46,901 WHH 111,151 Total 47k WHH 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-site 2 ”. 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 Source: 1 Provider returns 2015/16 24 Source: British Association for Emergency Medicine and The College for Emergency Medicine, Way Ahead, 2005

CONFIDENTIAL Wha hat num number r of of Med edic ical l Em Emergency Cen entres sho should ld be be con onsid idered for or 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 onsiderin ing tw two o Med edic ical l Emer ergency Cen entr tres in in ea east Ken ent. t. 26

CONFIDENTIAL In In add addit itio ion, to o mee eet t na nati tional l rec ecommendatio ions, the there is s curr currently ly onl only suf sufficie ient work orkforce to o pr provid ide a a Med edic ical l Em Emer ergency Cen entr tre at t tw two o si sites Which options achieve this? Recommendation Are we currently able to meet this? The Royal College of Physicians recommends that for an Acute Medical Unit (AMU) with 30 beds or QEQM WHH K&C A combined rota at less there is a requirement for 1 to 1.5 consultants currently currently currently no more than 2 sites on the AMU 8am-8pm has 5.9 has 9.4 has 5.0 would allow this consultants* consultants* consultants* standard to be met In order to provide 12 and 14 hour AMU consultant cover 10 consultants are required • 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 *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 SOURCE: Royal College of Physicians; Acute care toolkit 4 (2015); NHS provider information (2016) NOTE: *Acute physicians and HCOOP 27

CONFIDENTIAL Is Is the the op opti tion cli clinic icall lly sus sustain inable le? 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 Is it clinically services in EK including pPCI and renal are provided to a population of over 1m which would support a Major Emergency sustainable? 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. Criteria Implication Possible configurations ▪ Catchment suggests 0-1 MECS, 1-2 1. 1 MEC with specialist services ECs and 2-3 MedECs. 1) Is it 2. No more than 2 ECs ▪ Specialist services catchment means clinically 3. No more than 2 MedECs 1 MEC sustainable? ▪ Workforce and access mean 1-2 ECs ▪ Workforce limitations mean 2, not 3 MedECs 28

CONFIDENTIAL – Lon ong list t of of op optio ions rem emain inin ing for or ur urgent car are ser servic ices fol ollo lowing the the ana analysis is ag again inst t cli clinic ical l sus sustainabil ilit ity cri criterio ion Option 2 Option 3 Option 9 Option 1 Option 4 Option 5 Option 6 Site Option 7 Option 8 MedEC UCC MedEC UCC MEC K&C MEC EC ICH EC ICH MedEC MedEC UCC UCC WHH MEC MEC ICH EC EC ICH MedEC MedEC UCC UCC MEC MEC QEQM ICH ICH EC EC Green GFS MEC field site Single site on existing MEC site MEC Closing a site EC Major emergency centre Emergency centre None – no centre Urgent care centre Integrated care hospital Medical Emergency Centre with specialist services 29 Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it

CONFIDENTIAL Ana naly lysis is carr arrie ied out out by ea east t Ken ent sho shows tha that pr provis ision of of a a ne new gree eenfie ield ld si site or or si single le site op si opti tion on on cur current ac acute si site wou ould ld be be fi financia ially ly pr proh ohib ibit itiv ive • 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. *Detailed capital break down in appendix 31 SOURCE: east Kent clinical strategy, 2016

CONFIDENTIAL Analysis carrie ied ou out t by ea east t Ken ent shows th that t provision of of a new gr greenfiel eld sit ite e or or sin ingle gle sit ite e op opti tion on on cu current acu cute sit ite wou ould be fin financiall lly prohibitiv ive: acu cute med edical l bed eds nee eeded in in east t Ken ent by 2021 Estimated beds Beds WHH K&C QEQM Total 15/16 acute medical beds 1 235 211 216 662 20/21 acute medical beds 171 156 146 473 20/21 projected available space (total bed base – elective 85 51 91 226 and non elective) • 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 site 2 • 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 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 32

CONFIDENTIAL Ana naly lysis is carr arrie ied out out by ea east t Ken ent sho shows tha that the the clo closure of of one one si site and and rep eprovisio ion of of accommodatio ac ion on on the the rem emain inin ing ac acute si sites wou ould ld be be fi financially ly pr proh ohibit itiv ive • 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. *Detailed capital break down in appendix 33 SOURCE: east Kent clinical strategy , 2016

CONFIDENTIAL Rec ecent t ne new bui build lds de demonstr trates tha that t the the 20/2 /21 tim timeframe pr proh ohib ibits ts the the bui buildin ing of of a a new ac ne acute gree eenfie ield ld si site 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 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 Royal Derby Hospital (opened 2009) Time to build: 4 years Cost to build: £334m Total time to deliver: 7 to 9 years 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 34 Source: NHS Trust websites, accessed 2016

CONFIDENTIAL ERIC IC retu turns show th that t EKH KHUFT hos ospital 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 100 Percentage of estate built, split by date range of build % 90 80 71 70 60 54 50 41 40 31 31 30 23 22 21 19 18 20 16 15 11 9 8 10 5 3 1 0 0 0 William Harvey Hospital Queen Elizabeth The Queen Mother Kent & Canterbury Hospital National Average - Acute Hospital • 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. 35 Source: ERIC Returns 2016/17

CONFIDENTIAL Th The e 6 f facet sur survey sugg suggests ts EK EKHUFT es estate is s in n rea easonable le con ondit itio ion, sugg suggestin ing lar arge am amou ounts of of ne new es estate ar are e no not t ne needed for or qua quali lity rea easons Cost to % Clinical 6 Facet Energy Cost / Total backlog eradicate Trust / CCG Synopsis GIA m 2 Occupied m 2 Space (for Average GIA Cost (£) backlog per 2 of Space Carter) M Kent and Canterbury 56,023 55,81 4.8 24 17,390,000 310 67 4.80 Queen Elizabeth The 4.64 51,390 46,385 4.64 27 32,600,000 634 69 Queen Mother Hospital 4.80 William Harvey Hospital 61,814 58,157 5.93 30 24,050,000 389 66 Average per site 60,659 57,650 5 5 26 24,680,000 406 67 36 Source: ERIC Returns 2016/17

CONFIDENTIAL Is Is the the op opti tion impl plementable le? 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 . Implication Criteria Possible configurations • Only current sites considered due to time 2) Is it 1. WHH – any service can be here frame - any model at any site implementable? 2) Is it • 2. QEQM – any service can be here No greenfield site or single site option on a implementable? 3. K&C – any service can be here 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 37

CONFIDENTIAL List of of rem emain inin ing op optio ions tha that de deli liver r ur urgent care ser servic ices fol ollowin ing the the an analy lysis ag again inst impl im plementable le cri criterio ion Option 4 Option 1 Option 2 Option 3 Option 5 Option 6 Site MedEC UCC MedEC UCC MEC MEC K&C ICH ICH EC EC MedEC MedEC UCC UCC WHH MEC MEC ICH ICH EC EC MedEC UCC MedEC UCC QEQM MEC MEC ICH ICH EC EC Major emergency centre Integrated care hospital Medical Emergency Centre Urgent care centre Emergency centre with specialist services Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it 38

CONFIDENTIAL Do Does es th the e op opti 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: 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 The following slides outline the analysis undertaken to draw this conclusion 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. 40

CONFIDENTIAL Travel l tim time ana analysis onl only con onsid iders tho those affected by ser services movi ving away fr from om the their ir closest clo t si site in in ter erms of of tr travel l tim time • 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 WHH K&C QEQM Population for whom WHH is the Population for whom K&C is the Population for whom QEQM is the closest site = the impacted closest site = not the impacted closest site = not the impacted population population population 41

CONFIDENTIAL All l op optio ions with th onl only one one 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 o a a si site (eit (either r in in K& K&M or or pe peri riphery ry) ) with ithin 60 60 minu inutes Maximum travel time for impacted population* Peak Site Configuration Option If the EC was at WHH 60 mins NOTE: This analysis assumes that for each option patients will travel to If the EC was at QEQM 50 mins the next closest site in terms of travel time that is offering a service – this includes sites If the EC was at K&C 43 mins outside of East Kent *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 42 SOURCE: Base map; Carnall Farrar Analysis. Travel times by car

CONFIDENTIAL All ll op optio ions with ith tw two o Emergency Cen entres allo allow ac access to o a a si site (eit (either r in in K& K&M or or pe perip iphery) with thin 45 45 minu nutes Maximum travel time for impacted population* (rounded % impacted population able to access within X mins (peak) to nearest whole minute) Peak 60 45 Site Configuration Option 30 23% If the ECs were at QEQM 77% & WHH 34 mins 100% 100% 37% 1.4% If the ECs were at K&C & QEQM 43 mins 63% 100% 98.6% 19% If the ECs were at K&C 41 mins 81% & WHH 100% 100% 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 *Impacted population means that only the population whose closest service location in terms of travel time changed is analysed 43 SOURCE: Base map; Carnall Farrar Analysis. Travel times, peak, by car

CONFIDENTIAL Is Is the the op opti tion ac accessible le? RECOMMENDATIONS The analysis shows that: ICH/ UCC • 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 Implication Criteria Possible configurations No options fail the access criteria as all 1. WHH – any service can be here 3. Is it remaining options are within the average 1- 2. QEQM – any service can be here accessible? hour hurdle criterion for access 3. K&C – any service can be here 44

CONFIDENTIAL List of of rem emain inin ing op optio ions tha that de deli liver r ur urgent care ser servic ices fol ollowin ing the the an analy lysis ag again inst ac accessibili lity cri criterio ion Site Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 MedEC MedEC UCC UCC MEC MEC K&C ICH ICH EC EC MedEC MedEC UCC UCC WHH MEC MEC ICH ICH EC EC MedEC UCC MedEC UCC QEQM MEC MEC ICH ICH EC EC Major emergency centre Integrated care hospital Urgent care centre Medical Emergency Centre Emergency centre with specialist services Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it 45

CONFIDENTIAL Is Is the the op opti 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: 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. The following slides outline the analysis undertaken to draw this conclusion. 47

CONFIDENTIAL Is Is the the op opti 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 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. 48

CONFIDENTIAL In 2012, th In the e Sou outh 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 of a natio tional l des esign ignation proces ess Decision making Outcome Background • The designation process was developed in response to national • • In order to determine which Medway Maritime requirements set out in the revised NHS National Operating K&M hospitals should Hospital, William Framework. become TUs the Kent and Harvey Hospital and • It involved the development of local trauma units to provide Medway Trauma Network Tunbridge Wells enhanced services for patients following major trauma, and links with (KMTN) analysed the Hospital were rehabilitation pathways for all patients following treatment for major incidence of trauma in K&M designated as trauma trauma. Patients within 45 minutes of a major trauma centre (MTC) and produced isochrones units in 2012. The will be taken straight there for treatment; patients further than 45 showing the 45 minute road- Queen Elizabeth the minutes will be taken to trauma units (TUs) where their condition can travel times to local acute Queen Mother Hospital be stabilised. trusts. As a proportion of was designated as a • The 45 minute travel timeline was established based on a consensus patients would be Local Emergency of expert clinical opinion. subsequently transferred to Hospital with Helicopter • As there was an insufficient volume of patients to warrant a MTC the MTC, it was agreed that Emergency Medical being established in K&M, it was agreed that King's College Hospital the TUs would be best Services (HEMS) (KCH) in South London would take this position, building on placed on a route towards support. established links and patient flows. the MTC. • 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. 49 SOURCE: Proposal for the Development of Major Trauma Units for Kent and Medway , 2012, Major trauma care in east Kent2015

CONFIDENTIAL 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 or Ken ent and Med edway as s part rt of of a natio tional l des esign ignation process Background Decision making Outcome • • • In 2010, the Kent Cardiac Network (South East) The geographical location of WHH and associated WHH was designated to agreed that the Kent and Medway primary PCI transfer times are critical in the successful delivery provide Kent and service should be established at the William Harvey of the Kent primary PCI service. Medway primary PCI Hospital, Ashford (WHH) in-line with the service. • Commissioning intentions, National Policy, and best EKHUFT worked closely with the Kent Cardiac practice Network and South East Coast Ambulance Service • South East Clinical Senate also endorsed the (SECAMB) to review the travel times and isochrone decision of the Kent Cardiac Network that the Kent maps to ensure agreed call times can be met. and Medway primary PCI service should be These are as follows: ✓ established at the William Harvey Hospital, Ashford ‘Call To Balloon’ (CTB) – 120 minutes ✓ ‘Door To Balloon’ (DTB) – 90 minutes (WHH) • Kent and Medway primary PCI service was agreed • to be provided from the catheter laboratory at Evidence from SECAMB supports the achievement William Harvey Hospital (WHH), Ashford. This of the above standards; the shortest times being facility has been approved by the British achieved by direct admission to the catheter Cardiovascular Intervention Society (BCIS) since laboratory in the primary PCI Centre at WHH. This November 2005 evidence was submitted, discussed, reviewed and • The WHH service was the nominated provider for all agreed by the Kent Cardiac Network Board 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 50

CONFIDENTIAL 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 ollowin ing Sou outh Eas ast Coa oast t Clin linic ical l Sen enate rec ecommendatio ions Key Emergency Department Acute cardiology Anaesthetics Plastic surgery (unselected) Additional services that Critical care (L1, L2 & 3) General surgery Acute oncology Co-location on should in-reach if Acute and general same site not based on- medicine (inc. AMU) Clinical microbiology Acute gynaecology Palliative care site Liaison psychiatry Elderly medicine Trauma Rheumatology Specialist Diagnostics inc. MRI Respiratory medicine Orthopaedics* services Dermatology Urgent haematology Medical gastroenterology Urology* Maxillo-facial surgery Support services Support services (see key) ENT* Urgent GI endoscopy ▪ Co-located Neurology – Social care Nephrology (not including Trauma unit Interventional cardiology – Physiotherapy • dialysis) Acute paeds (PC/i) Burns – Occupational Therapy – Lab based diagnostics Vascular surgery (spoke) Consultant-led obstetrics Acute stroke unit – Interventional radiology Emergency imaging and Inpatient rehabilitation reporting Vascular surgery (hub) ▪ Acute paediatrics* Ideally co-located Diabetes & endocrinology • HASU – Hyper acute stroke unit Speech and language • Interventional radiology therapy Ophthalmology – 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 51

Th The e Keo eogh rep eport rt (20 (2014) ) se sets out out the the ser servic ices of offered fr from om a a Majo ajor r Em Emer ergency Cen entre and WHH alr an already pr provid ide the these ser services Services Currently Offered What Centre Services QEQMH • Larger units, capable of assessing WHH and initiating treatment for all Major Hyper-acute Cardiac (pPCI)* √ X Emergency patients and providing a range of Centre with Stroke √ √ specialist hyper-acute services Specialist Full Obstetrics √ √ • Service population of Services level 3 NICU √ X approximately 1-1.5m Trauma unit √ X Level 3 ICU √ √ * Single Kent & Medway Percutaneous coronary intervention (PCI) since 2010 In addition, there are key services provided at the WHH that support its development as a Major Emergency Centre Single inpatient Head & Neck Unit (Ophthalmology, ENT and Maxillofacial including complex cancer activity) and therefore in all options where emergency services remain on two sites, the MEC with specialist services should be at the WHH and not QEQMH 52

CONFIDENTIAL Is Is the the op opti 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. 53

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 Dates Consultation Key service changes/Impact / Outcome • 1 Dec 2001 - Feb 2002 Modernising Hospital services Reviewed A&E and general medicine, renal, dermatology, urology, in east Kent 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 Inpatient elective orthopaedic surgery, inpatient breast surgery, inpatient Reconfiguration Plan neurology, dermatology and inpatient clinical haematology • 3 July 2003 - Sep 2003 Kent and Medway review of Review of Kent and Medway’s renal, vascular surgical and interventional Renal and vascular services 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) 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) 54

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 55 SOURCE east Kent Hospitals Reconfiguration Plan – 2003 Public Consultation Document

CONFIDENTIAL Previ vious con onsult ltatio ion: History ry of of the the de decis ision-makin ing pr process for or east Kent’s two -sit ite Acu cute Inp Inpatie ient Mod odel • East Kent Health Authority - Tomorrow’s Healthcare concluded that it was not possible to retain major and complex services on all three ma in 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 Healt h 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 56 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.

CONFIDENTIAL Previo ious con onsult ltatio ion: His istory ry of of the the de decis ision-makin ing pr process for or east Kent’s Two-sit ite Acu cute Inp Inpatie ient Mod odel • 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 gre atest 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 57 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.

CONFIDENTIAL Th The e 2011/2 /2012 Maternit ity ser servic ices rec econfig iguratio ion • 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: o 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; o A new midwife-led birth centre in Margate (co-located with the acute obstetric ward) would open to provide four extra labour/postnatal beds; Maternity services o An increase in births at Ashford would be possible in the midwife-led unit and two more labour reconfiguration beds would soon be available; and o 25 per cent of women who transfer to a consultant-led centre due to complications would no longer need an ambulance journey. 58 SOURCE Joint Maternity Services Review public consultation document, 14 October 2011

CONFIDENTIAL 77 77 % % of of the the im impa pacted po popula latio ion ar are ab able le to o ac access ur urgent t car are ser services with ithin in 30 minu nutes if f the the tw two o Med edECs si sites ar are e located QEQM and and WHH Maximum travel time for 30 minutes access impacted population* Peak Peak Site Configuration Option 23% If the Med ECs were at Able to access 34 mins 77% site within QEQM & WHH 30mins Not able to 37% If the Med ECs were at access site 43 mins K&C & QEQM within 30mins 63% 19% If the Med ECs were at 41 mins K&C & WHH 81% 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 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 *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 59 SOURCE: Base map; Carnall Farrar Analysis. Travel times, by car

CONFIDENTIAL Is Is the the op opti 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). Criteria Implication Possible configurations • Trauma unit designated at WHH due to location – 1. WHH – MEC with specialist services therefore WHH must be MEC 4) Is it 2. QEQM – EC, MedEC • pPCI designated at WHH due to location – ideally a strategic fit? 3. K&C – ICH/UCC 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) 60

CONFIDENTIAL List of of rem emain inin ing op optio ions tha that de deli liver r ur urgent care ser servic ices fol ollowin ing the the an analy lysis ag again inst str trategic fi fit t cri criterio ion Option 4 Site UCC K&C ICH WHH MEC MedEC QEQM EC Major emergency centre Integrated care hospital Medical Emergency Centre Urgent care centre Emergency centre with specialist services Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it 61

CONFIDENTIAL Ass ssessing the the impa pact of of 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 clinically sustainable over the medium to long term? Is the option implementable by 20/21? Does the option have strategic fit with other recent consultations or designation processes? Does the option deliver accessible services? Is the option financially sustainable over the medium to long term? 62

CONFIDENTIAL Ass ssessing whe hether r the the op optio ions ar are e fi financia iall lly via viable le over er the the med ediu ium term erm to o lon ong ter erm 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. • 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. 63

CONFIDENTIAL Closin ing the the pr proj ojected 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 £ millions, Kent and Medway health system 122 -122 12 -29 190 -294 102 51 -139 50 TBC -434 Provider CCG Social care Total QIPP Spec Care Productivity Enablers System STF STF Financial challenge challenge challenge system Comm Trans- incl. CIP Leadership funding investment challenge, challenge QIPP formation 2020/21, post- intervention • • Assumes 100% investment of STF funding to deliver Outstanding gap relates to £29m funding transformational change and service developments for Ebbsfleet growth by 2020/21 • • Further work required to refine this need Also a capital implication of £75m 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. 64 Source: STP financial template

CONFIDENTIAL Th Ther ere will ll be be bot both fi financia ial l be benefit its an and cos osts fr from om consolid idatin ing ser services whi hich will ll ne need to o be be wor orked thr throu ough as as pa part t of of the the ne next t eval aluatio ion of of op optio ions • Staff savings from consolidation/networking of rotas • Consolidation of elective activity • Consolidation of support services + The following will result • Removing stranded estate in savings from making • Impact of QIPP changes • Note: assume there is no additional agency or clinical / non-clinical supply cost benefits as these are being recognised by the productivity opportunity • Additional transportation costs - • Capital charges / implications from capital investment These items will be an • Transition costs additional cost pressure • Communications and public consultation from making changes The benefits and costs will be analysed in granular detail at the evaluation stage. It is assumed that the overall revenue costs (excluding revenue costs of capital) of consolidation do not differentiate between options at the hurdle criteria stage. 65

CONFIDENTIAL If If QEQM is is a a Med edic ical l Emer ergency Cen entre, it it wou ould ld req equire 136 ad addit itional l be beds at t WHH WHH 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 Inpatient beds Actual beds 15/16 Growth by 20/21 20/21 local care After service reconfiguration Final Bed interventions Requirement Sites Increase Baseline New Total Reduction New Total Bed Changes Total Required Bed Balance Demand WHH 447 124 571 -193 378 +205 583 -1 36 QEQM 368 121 489 -197 292 +7 299 +69 K&C 277 325 233 -233 0 +277 48 -92 Total 1,092 903 - 21 882 210 293 1385 -482 • 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. 66 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.

CONFIDENTIAL Even if f ele electiv ive act activ ivity ty is s rem emoved fr from om WHH, 92 add additio ional l be beds wou ould ld be be req equired for or QEQM to o be be an an Med edic ical l Emer ergency Cen entr tre 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 Inpatient beds Actual beds 15/16 Growth by 20/21 20/21 local care interventions After service reconfiguration Final Bed Requirement Sites Increase Baseline New Total Reduction New Total Bed Changes Total Required Bed Balance Demand WHH 447 124 571 -193 378 +161 539 - 92 QEQM 368 121 489 -197 292 +25 317 +51 K&C 277 325 233 -233 0 +277 48 -92 Total 1,092 903 - 47 856 236 293 1385 -482 • 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 67 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

CONFIDENTIAL Is Is the the op opti 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. Criteria Implication Possible configurations • Under a two-site option, QEQM is an EC 1. WHH – MEC with specialist services as capacity required due to patient flows Is it 2. QEQM – EC is too large for WHH to accommodate financially 3. K&C – ICH/UCC sustainable? 68

CONFIDENTIAL Rem emainin ing op optio ions tha that de deli liver r ur urgent t car are ser services fol ollo lowin ing the the an analy lysis is ag again inst financial sus fi sustain inabil ility ty cri criterio ion Site Option 4 UCC K&C ICH WHH MEC QEQM EC Major emergency centre Emergency centre Urgent care centre Integrated care hospital with specialist services Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it 69

CONFIDENTIAL Sum ummary ry of of the the app applic icatio ion of of Hur urdl dle Crit riteria ia ag again inst t EK EK ur urgent t car are op optio ions Criteria Implication Possible configurations ▪ Catchment suggests 0-1 MECS, 1-2 ECs and 2-3 MedECs. 1. 1 MEC with specialist services ▪ Specialist services catchment means 1 MEC 2. No more than 2 ECs 1) Is it ▪ Workforce and access mean 1-2 ECs 3. No more than 2 MedECs clinically ▪ Workforce limitations mean 2, not 3 MedECs sustainable? • Only current sites considered due to time frame - any model at any site 1. WHH – any service can be here • No greenfield site or single site option on a current acute site to be 2. QEQM – any service can be here considered due to timeframe and cost 2) Is it 3. K&C – any service can be here • No fewer than 2 sites with acute medical beds Implementa- • No complete closure and reprovision of any single site will be considered ble ? 1. WHH – any service can be here • No options fail the access criteria as all remaining options are within the 3) Is it 2. QEQM – any service can be here average 1-hour hurdle criterion for access accessible? 3. K&C – any service can be here • Trauma unit designated at WHH due to location – therefore must be MEC • pPCI designated at WHH due to location – ideally should be MEC 1. WHH – MEC with specialist services 4) Is it • QEQM could either be an Emergency centre (EC)and/or a Medical emergency 2. QEQM – EC, MedEC a strategic centre (MedEC) 3. K&C – ICH/UCC fit? • K&CH would be an integrated care hospital (ICH)/Urgent care centre (UCC) 1. WHH – MEC with specialist services • Under a two-site option, QEQM is an EC as capacity required due to patient flows 5) Is it 2. QEQM – EC is too large for WHH to accommodate financially 3. K&C – ICH/UCC Sustain- able? 70 *All MECs are also a EC and an MedEC, all ECs are also an MedEC

CONFIDENTIAL Con ontents Background Agreed K&M Fixed Point Criteria Urgent care services Applying the hurdle criteria on urgent care options Single site developer options at K&CH Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Appendix 71

CONFIDENTIAL In Intr troductio ion of of a a si single le si site de developer r op opti 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 w ould 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 outset. 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. 72

CONFIDENTIAL Th The e ser servic ice mode odel wou ould ld see see the the de deli livery ry of of 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 Peripheral sites would provide: Other opportunities for the A single MEC would contain • GP led UCC; • 24/7 emergency department with peripheral sites • outpatient services; • Primary care; trauma; • fracture clinics; • Emergency services e.g. medicine; • Social services; • day surgery; • Community rehab; HCOOP and surgery; • ambulatory care; • In-patient gynaecology and • Voluntary services; • diagnostics; • Nursing home; obstetrics; • pharmacy; • In-patient child health services; • Community services. • therapies; • Critical care; • renal dialysis; • Trauma unit; • chemotherapy; • Diagnostics; • elective endoscopy; • Interventional radiology; • ambulatory paediatrics; • Specialist services: • maternity day care; • NICU / Special Care Baby Unit; • neuro-rehabilitation beds; • Renal; • step up / step down beds. • Head and neck cancer (incl ENT); • Vascular; • Urological cancer; • Haemat-oncology and OP haemophilia; • HASU & ASU; • pPCI; • Gynae-oncology. 73

CONFIDENTIAL Final l med ediu ium list for or Ur Urgent Ca Care Options Site Option A Option B UCC MEC K&C ICH UCC WHH MEC ICH UCC EC QEQM ICH Major emergency centre Integrated care hospital Emergency centre Urgent care centre with specialist services Note: MEC includes both an EC and a MedEC within it and an EC includes a MedEC within it 74

CONFIDENTIAL Con Conten ents Background Agreed K&M Fixed Point Criteria Urgent care services Applying the hurdle criteria on urgent care options Single site developer options at K&CH Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Appendix 75

CONFIDENTIAL Cas ase for or Cha hange of of the the pri priorit itis ised ser servic ices for or Pha hase 1 Con onsultatio ion in n ea east Ken ent Service Case for Change Implications • A rise in the elderly and obese population is driving an increase in demand • Significant opportunities to improve • Waiting lists for planned care are growing efficiency and quality by Elective • Pressure from emergency patients requiring admission is increasing the standardising planned care to best Orthopaedics number of on the day cancellations. practice by consolidating elective • Patient experience and outcomes could be improved inpatient orthopaedics. • Workforce constraints prevent the delivery of 7 day services and 24/7 • The configuration of acute medicine a consultant cover across most hospitals in east Kent. sites should be optimised according Acute • In some hospitals, senior doctors are not present at the weekend or are trying to Keogh definitions to deliver more medicine to cover more than one clinical area at a time. senior doctor cover. • Support services for discharge are also not available at the weekend. Urgent care • Across K&M, attendances to major ED departments have risen by 2.2% per • The configuration of acute medicine b year over the last 3 years (twice the national average) sites should be optimised according • Providers have some of the worst patient satisfaction scores in the country for to Keogh definitions. Emergency ED Departments • 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%). • National guidelines state that specialist doctors, nurses and therapists should • Urgent need to consolidate services be available 24/7; none of the hospitals in east Kent achieve this. to improve quality and reduce Stroke • No hospital in east Kent thrombolyses all eligible stroke patients within the likelihood of excess mortality. national guideline recommended time of 60 minutes. • • It has been agreed that a single There are two hospitals in K&M that provide emergency vascular services and neither meet the majority of the national guidelines. vascular service will be delivered • There is no 24/7 access to specialist vascular care across K&M with a arterial centre on Vascular • There is an agreed network strategy across EKHUFT and MMFT one site 76 SOURCE: Kent & Medway Case for Change, Carnall Farrar analysis

CONFIDENTIAL CCG Discussio ion 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. 77

CONFIDENTIAL Cas ase for or ch change for or ele electiv ive ort orthopaedic ic sur surgic ical l ser servic ices 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. Source: 1 The reconfiguration of clinical services” (2014) The Kings Fund 78

CONFIDENTIAL Case ase for ch change for ele lective ort orthopaedic ic su surgical se services 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 79 Source of Consultant-led Referral to Treatment Waiting Time Data : NHS England, Provider based, September 2014, 2015, 2016

CONFIDENTIAL Scope of of el electiv ive ort orthopaedic 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 or 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. 80

CONFIDENTIAL Con Conten ents Background Agreed K&M Fixed Point Criteria Urgent care services Applying the hurdle criteria on urgent care options Single site developer options at K&CH Elective orthopaedics services Applying the hurdle criteria on elective orthopaedics options Appendix 81

CONFIDENTIAL A set t of of hurdle crit criteria ia have e bee een agr greed by th the e Clin Clinical l Boa Board and Fin inance e wor orking Group • Does it deliver key quality standards? Is the potential • Does it address any co-dependencies? configuration • Will the workforce be available to deliver it? option clinically • Will there be sufficient throughput or catchment population to maintain skills and deliver sustainable? services cost effective? • Is the potential Will the option deliver financial and clinical sustainability within a medium-term configuration timeframe by 20/21? This statement is based upon a system wide view, this may mean option that some organisations have a net negative financial impact as well as some have a net implementable? positive impact. Is the potential • Is the maximum travel time (by car) an average of one hour or less? configuration option accessible? Is the potential configuration • Does it implement the outcome of other recent consultations or designation processes? option a strategic fit? Is the potential configuration • Must not increase the ‘do nothing’ financial baseline option financially sustainable? 82

CONFIDENTIAL Develo lopin ing the the op optio ions s for or elec electiv ive ort orthopaedic ic se servic ices s acr cross s ea east Ken ent In east Kent, there is one trust (east Kent Hospitals Foundation Trust - EKHUFT) providing inpatient elective orthopaedic services across two main acute sites (William Harvey Hospital – QEQM WHH and Queen Elizabeth the Queen Mother Hospital). This service could be provided on: • 3 sites • 2 sites K&C • 1 site • 0 sites Applying the hurdle criteria to WHH assess the options for the identified services will result in a medium list of potential viable options for evaluation in further detail. 83

CONFIDENTIAL In 2015/16 the there e wer ere e 9,882 elec elective e (i (inpatie ient and day case se) ort orthopaedic ic proc ocedures s under ertaken in ea east Ken ent • The South East Coast H Clinical Senate reflected Queen Elizabeth the that large units Queen Mother Hospital H H undertaking 3,000 or more joint procedures would enable delivery of the IP 1,528 standards/improvements Kent and Canterbury DC 1,392 H H Hospital • In 2015/16, the Trust IP 75 undertook 3,675 elective DC 1,571 inpatient procedures and H H IP 2.072 IP 2,072 outsourced a further 743 DC 3,244 DC 3,244 elective inpatient William Harvey procedures giving a total Hospital (Ashford) of 4,418 procedures. Out of this, 3,060 procedures related to joint surgery (shoulder, knee, elbow, hip, etc). IP = In patient DC = Day case Note: Day case include some non-elective activity Note: Source: Provider data returns, Elective orthopedics activity, FY2015-16 84 Note: source South East Coast Clinical Senate review of clinical models

CONFIDENTIAL The e foll ollowing sp speci ecific icatio ion for or an elec elective e cen centre has s bee een agr gree eed Specialised emergency Key Non-complex inpatient surgical opinion surgery (85%) Co-location Acute medical opinion and Networked Non-complex day case assessment on same site services surgery (99%) Acute medical intervention Support services Anaesthetics ▪ Co-located Critical care Simple diagnostics – Physiotherapy – Occupational Therapy Support services (see key) Lab based diagnostics – Emergency imaging and reporting Specialist imaging Outpatient services *The presence of L2 critical care will mean a more complex case mix can be seen. 85 Source: Carnall Farrar analysis based on collected clinical opinion

CONFIDENTIAL Lon Long list of of op optio ions s for or elec electiv ive ort orthopaedic ic se servic ices s in ea east Ken ent Option 2 Option 3 Option 1 Option 4 Option 5 Option 6 Option 8 Site Option 7 MedEC MEC MEC K&C EC ICH EC ICH ICH EC MedEC EC ICH ME EC MEC MEC EC MEC MedEC GFS WHH QEQM Single site for Kent & Medway None – no centre Elective inpatient orthopaedic centre MEC MEC 86

CONFIDENTIAL As Asse sess ssin ing the the impact of of 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 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? Is the option financially sustainable over the medium to long term? 87

CONFIDENTIAL Is s the the op optio ion cl clin inic icall lly su sustainable le? • 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). Inpatient el Inp electiv ive orth orthopaedic volu olumes s sugg suggest that an an el elective orth orthopaedic ser service is s req equired an and sustain sus inable le in eas east t Kent Therefore, the option not to have an elective orthopaedic service in east Kent has been discounted Note: Day case include some non-elective activity Source: Provider data returns, Elective orthopedics activity, FY2015-16; 1) http://www.eoc.nhs.uk/ 88

CONFIDENTIAL Is s the the op optio ion cl clin inic icall lly su sustainable le? 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 • 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 Therefore, the option to have a single elective orthopaedic service for Kent and Medway has been discounted • N.B. Kent Institute of Medicine and Surgery (KIMS) currently has 5 theatres and 72 in-patient beds 89

CONFIDENTIAL Furt rther evid idence suggests in incr creased volu olume and speci ciali lisation can im improve ou outcomes in in speci ecialist surgery ry, str trength thening th the e case e for or not ot in increasing th the e number of of sit ites es • 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. Positive volume/outcome relationship found, % Specialty Overall Mortality LOS Complication rate No. of studies Hospital volume 1 All specialties 74 76 79 62 127 Surgeon volume 1 All specialties 74 71 78 81 58 • 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 4.7 5.0 6.0% 4.4 4.2 4.2 4.2 5.0% 4.0 4.0% 3.0 3.0% 2.0 2.0% 1.0 1.0% 1 2 3 4 5 0 0% Least specialised Most specialised Mean LoS (days) 90 day composite outcome 90 Source: British Journal of Surgery, A systematic review of the impact of volume of surgery and specialisation on patient outcomes, 2007; 94; 145 – 161

CONFIDENTIAL Is s the the op optio ion cl clin inic icall lly su sustainable le? RECOMMENDATIONS The analysis shows that: • In-patient elective orthopaedic services are currently provided at two main acute sites in east Kent (WHH and QEQM) Is it clinically sustainable? • 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 . Criteria Implication Possible configurations ▪ In-patient elective orthopaedic Any 1, 2 or 3 site option for east Kent 1) Is it services will be delivered from either clinically 1, 2 or 3 sites in east Kent sustainable? ▪ Single site for Kent and Medway has been discounted 91

CONFIDENTIAL Rem emain inin ing list of of op optio ions s for or elec electiv ive ort orthopaed edic se servic ices s foll ollowing appli lication again inst the the clin cl inic ical su sustain inabil ility cri criterio ion Option 3 Option 2 Option 4 Option 5 Option 6 Option 7 Site Option 8 K&C MEC MEC EC EC MedEC ICH ICH MedEC MedEC ME MEC WHH ICH EC EC MEC MEC QEQM ICH EC EC GFS MEC None – no centre Elective inpatient orthopaedic centre MEC MEC 92

CONFIDENTIAL What opti tions are im imple lementable le by 20/21? • 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 Therefore, all remaining options are considered implementable 94 Source: Provider returns (2015), Carnall Farrar analysis (2017)

CONFIDENTIAL Is s the the op optio 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. Implication Criteria Possible configurations 2) Is it ▪ In-patient elective orthopaedic implementable? Any 1, 2 or 3 site options for east Kent 2) Is it services will be delivered from either implement 1, 2 or 3 sites in east Kent able? 95

CONFIDENTIAL Rem emain inin ing list of of op optio ions s for or elec electiv ive ort orthopaed edic se servic ices s foll ollowing appli lication again inst the the imple lementable le cri criterio ion Option 3 Option 2 Option 4 Option 5 Option 6 Option 7 Site Option 8 K&C MEC MEC EC EC MedEC ICH ICH MedEC MedEC ME MEC WHH ICH EC EC MEC MEC QEQM ICH EC EC GFS MEC None – no centre Elective inpatient orthopaedic centre MEC MEC 96

CONFIDENTIAL Doe oes the the op optio ion deliv eliver er acces ccessib ible le se servic ices? s? 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 Maximum travel time for impacted population* Peak Site Configuration Option If the in patient elective orthopaedics 59 mins NOTE: were only offered at WHH This analysis assumes that for each option If the in patient elective orthopaedics patients will travel to the 50 mins next closest site in terms were only offered at QEQM of travel time that is offering a service – this includes sites outside of If the in patient elective orthopaedics 43 mins East Kent were only offered at K&C All patients live within 60 minutes travel time of an elective orthopaedic service *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 98 SOURCE: Base map; Carnall Farrar Analysis. Travel times,, by car

CONFIDENTIAL Doe oes the the op optio ion deliv eliver er acces ccessib ible le se servic ices? s? RECOMMENDATIONS The analysis shows that: • In any option 100% of the impacted population can access this service within 60 minutes Is it clinically sustainable? 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. Criteria Implication Possible configurations ▪ In-patient elective orthopaedic Any 1, 2 or 3 site options for east Kent 3) Is it services will be delivered from either 1, 2 or 3 sites for east Kent accessible ? 99

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