1. society
2. welfare
3. healthcare
4. hospital

Item 6a
Paper 3
Cover Sheet: Governing Body
Date
19 March, 2014
Title of paper
Ealing Hospital: Design Guide for the proposed future Hospital
Presenter &
Organisation
Sam Burrows and Kathryn Magson, Ealing CCG
Author
North West London Strategy & Transformation Directorate
Responsible director/ Mohini Parmar, Ealing CCG
Clinical Lead
Confidential
Yes
No X
The Governing body is asked to:
Endorse the information regarding the models of care set out in the Ealing Hospital Design Guide for
inclusion in the Ealing Hospital Outline Business Case.
Summary of purpose and scope of report
The ‘Design Guide’ for the proposed Local Hospital sets out the proposed model for the future hospital and
the services that are planned to be delivered from the current Ealing Hospital site. This document supports
the Outline Business Case (OBC) that is currently being developed for submission to the Ealing Hospital
Trust Board for their meeting on 27 March.
Shaping a Healthier Future (SaHF) set out their vision and future model for how services would be
configured across the region. These changes focused on:
• Centralising specialist services which people need when they are seriously ill,
• Localising the most common services people need for everyday illnesses and injuries,
• Integrating all of these services with others such as social care
For Ealing this means:
• Ealing Hospital will be developed as a local hospital. The Local Hospital will provide the majority of
services currently delivered, with the exception of A&E services (which have changed) and elective
services (which will be delivered elsewhere).
• Those patients who are most ill will be treated at one of the major, or specialist hospitals. They may
also choose to have treatment, such as a hip replacement at an elective hospital.
• Patients in need of emergency care will most likely be taken to a specialist unit by Ambulance. Local
Hospital staff will be trained to transfer patients quickly and safely to the appropriate setting.
• Services delivered in the Local hospital will be supported by transformed Out of Hospital care. Services
will be provided in peoples homes, at GP practices, across networks of GPs and other providers and at
Local Health and Wellbeing Centres.
• Many of the services delivered at Ealing Hospital, such as therapies and some outpatients, will be
delivered at locations across the borough and at the Local Health and Wellbeing Centres.
• Services to support patients when they are seriously ill will be transferred to hospitals in other parts of
North West London. These include; Northwick Park, Hillingdon and West Middlesex.
• Patients will have a more ‘joined up’ experience of care as a result of integrating services across
primary, secondary, mental health and social care
As part of the overall changes proposed to the NW London Health system, the development of a Local
Hospital within Ealing will act as a platform to support and drive the necessary changes. The Local Hospital
will act as an integral part of the system providing services focused towards holistic patient centred care
that responds to the physical, social and mental health needs of the community. In practice, this means
local patients, patient groups, the voluntary sector, the local council and local clinicians will be involved in
developing and running the Local Hospital.
Business Case Approval Process
The Local Hospital design follows work completed during the development of the Shaping a Healthier
Future Design Making Business Case which considered the impact on different equality groups. The Local
Hospital also forms part of our OOH infrastructure which aims to improve access to improve services for all
groups.
To deliver the SaHF programme a total of 7 OBCs are being produced across NW London – this document
will support the development of the Ealing LB OBC. Following the consideration of the OBC by their
respective hospital trusts they will undergo a detailed review the outcome of which will assure the
Commissioners across NW London of the feasibility of delivering these changes and impacts on areas such
as equalities. The charts below set out the business cases being developed across NWL and the process for
approval and assurance:
Business Cases being developed across NW London
Proposed process for assurance, commissioner support and Trust Board approval of a provider business
case.
Supporting documents
- Ealing Hospital: Design Guide for the proposed future Hospital
Quality & Safety/ Patient Engagement/ Impact on patient services:
Ealing CCG has made an ongoing commitment to capturing public feedback and patient experiences. This
information is gathered through a number of conduits, including public stakeholder meetings, the four local
community networks, local voluntary sector forums, focus groups, partnership boards, a range of patient
and carer-led groups, HealthWatch, complaints, Patient Participation Groups at local GP practices, and via
patient representatives.
A range of engagement activities have taken place to support the development of our Out of Hospital
Strategy and Specification for the Local Hospital. The key events and findings are set out below and these
themes have been addressed throughout the document.
Patient feedback and research shows that patients expect a health system that delivers better quality, more
accessible and more co-ordinated healthcare in and out of hospital. Patients have told us what they want
from all out of hospital services and from primary care their feedback is important in building our plans to
deliver out of hospital care.
Equality / Human Rights / Privacy impact analysis
To deliver the SaHF programme a total of 7 OBCs are being produced across NW London – this document
will support the development of the Ealing LB OBC. Following the consideration of the OBC by their
respective hospital trusts they will undergo a detailed review the outcome of which will assure the
Commissioners across NW London of the feasibility of delivering these changes and impacts on areas such
as equalities. This process is set out in the diagram above. The Decision-Making Business Case that
recommended Ealing should be developed as a local hospital completed a detailed equalities assessment.
Financial and resource implications
The Outline Business Case will include all financial and resource implications. These implications will be
reviewed through the approval process outlined above.
Risk
The outline business case will included a full risk assessment
Governance and reporting (list committees, groups, or other bodies that have discussed the paper)
Committee name
CCG Executive
Date discussed
05/03/2014
Outcome
Recommend to Governing Body
Delivering
Shaping a healthier future
Ealing Local Hospital Design Guide
Draft V4.0
Shaping a healthier future
Draft v4.0
Contents
1
Executive Summary
1
1.1
Purpose and context
1
1.2
The role of the Local Hospital
1
1.3
Service provision
1
1.4
Workforce
3
2
Introduction
4
3
Developing a service user centric Local Hospital model
5
3.1
Working with service users
5
3.2
What patients have told us about our current services
6
3.3
Patient expectations from primary care
6
3.4
Patient expectations as a service user
7
4
Context for the Local Hospital
8
4.1
Context of Shaping a Healthier Future Programme
8
4.2
The case for a Local Hospital
9
4.3
Improving the experience of patients and reducing the cost of care
9
5
Role of Ealing Local Hospital
12
5.1
Introduction
12
5.2
Patient-centred principles for a Local Hospital
15
5.3
New models to deliver 21st century care
16
5.4
Role and Benefits of the Local Hospital
18
6
Service provision
21
6.1
Introduction
21
6.2
Services to be provided from Local Hospital
22
Appendix A – Process to develop specification
Appendix B – Detailed case for change
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Contents
Shaping a healthier future
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Table of Figures
Table 1:1 – Services and key components ......................................................................... 2
Table 2:1 – What this document does and does not do ...................................................... 4
Table 4:1 – Patient experience: in the future .....................................................................10
Table 5:1 – Role and benefits of the Local Hospital ...........................................................20
Table 6:1 – Overview of services delivered from the Local Hospital ..................................22
Table 6:2 – Primary care services – activity and size ........................................................25
Table 6:3 – Urgent and Emergency Care – activity and size .............................................28
Table 6:4 – access to specialist opinion/outpatients - activity and size ..............................31
Table 6:5 - specialist outpatient services - activity and size ...............................................31
Table 6:6 - health and social care co-ordination - activity and size ....................................33
Table 6:7 - therapies - activity and size .............................................................................33
Table 6:8 - Patients over 65 with multiple long term conditions .........................................34
Table 6:9 – Number of beds at Ealing Local Hospital ........................................................36
Table 6:10 - bedded care - activity and size ......................................................................37
Table 6:11 - diagnostics and pharmacy - activity and size .................................................38
Table 6:12 – education and wellbeing – activity and size ..................................................40
Table of Figures
Figure 3:1 – Summary of engagement events to develop the OOH Strategy and Local
Hospital Specification................................................................................................... 6
Figure 3:2 – Patient expectations from primary care........................................................... 7
Figure 4:1 - Patient experience: today ...............................................................................10
Figure 5:1 – The role of the Local Hospital within Ealing ...................................................14
Figure 5:2 – Whole systems patient segmentations ..........................................................16
Figure 5:3 – The role of the Local Hospital within NW London ..........................................18
Figure 6:1 – Local Hospital functions [to be updated] ........................................................22
Figure 6:2 - Patient experience of the LECC .....................................................................27
Ealing Local Hospital Design Guide draft v3.0
Contents
Shaping a healthier future
Draft v4.0
1 Executive Summary
1.1 Purpose and context
This document – the Local Hospital Design Guide – provides a blueprint for commissioners of
healthcare services. It is designed to guide decisions about the services commissioned, so that the
Local Hospital realises the intended improvements in patient experience and health outcomes.
The specification sets out the functions of the Local Hospital, the services that will be provided, the
associated activity and the impacts on services across the borough.
The model described here reflects the findings of patient engagement and research led by Ealing
CCG (see section 2). It aligns with the direction of the Shaping a Healthier Future (SaHF) programme
and work being undertaken across NW London on integrated and out-of-hospital care. The
specification provides guidance to enable commissioners to make decisions which are consistent
with this wider strategy and case for change. Section 3 gives further detail on the strategic context.
1.2 The role of the Local Hospital
The role of the Local Hospital is central to the wider reconfiguration of health and care services
across NW London, by enabling CCGs to realise their vision to localise, centralise and integrate
services. It will be an intermediary and point of transition – between primary, community supporting
delivery of out-of-hospital care, specialist and acute care settings. The Local Hospital will act as a
Health and Wellbeing Centre, maintaining a network of health and care functions. It is the Local
Hospital’s ability to connect and coordinate services, drawn from across NW London, around the
needs of local patients, which is at the heart of its role.
This role definition reflects eight patient-centred principles, distilled from engagement with patients
and the community. Section 5 provides a detailed description of the role and underpinning principles.
1.3 Service provision
Section 6 identifies the core services that will be provided from the Local Hospital, grouped around
six functions:
•
•
•
•
•
•
Primary care services (GP practice)
Urgent and emergency services
Care assessment, coordination and Delivery
Transitional and rehabilitation care
Diagnostics and pharmacy
Education and wellbeing
Services will deliver holistic patient-centred care by addressing the patient’s physical, mental and
social care needs. They will help to prevent acute admissions, improve integration between health,
social and mental health services, and improve discharge from acute settings.
For each, an overview of the service is described, together with anticipated activity, size and
workforce needs. The service, their components and functions are summarised in the table below:
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Table 1:1 – Services and key components
Category
Service
Key components
Primary care led
services
GP Practice
•
•
•
•
GP appointments
Nurse appointments
Core GP services
Enhanced services including minor surgery
Urgent and
1
Emergency Care
Ealing Local Hospital
A&E
•
•
•
•
•
•
Minor illness
Minor injury
Mental health liaison
Primary care assessment
Access to Diagnostics (incl. x ray, ultrasound, ECG/Echo tests,
CT, MRI)
Near patient testing
Ambulatory Care unit
•
•
•
•
Possible DVT/Confirmed DVT
Unilateral limb cellulitis
Confirmed PE
Confirmed Unilateral Pleural Effusion
Outpatients/ access
to specialist opinion
•
•
•
•
•
•
•
•
•
•
Cardiology
Dermatology
Diabetes centre of excellence
ENT
Frail & Elderly care centre
Gastroenterology & colorectal
Gynaecology
Haematology
Infectious diseases including tuberculosis & hepatitis
Patients with long term conditions including cardiac failure, CVD,
respiratory conditions, cancer
Trauma & orthopaedics including MSK & pain management
Neurology
Paediatrics
Respiratory
Rheumatology
Sexual health
Urology
Vascular
Care assessment,
coordination and
delivery
•
•
•
•
•
•
•
•
Care coordination
•
Planning patients treatment programme through support to
navigate services across physical health, mental health and
social care services
Therapies
•
Therapy services including physiotherapy, dietetics, occupational
therapy, speech & language. The space will include gym facilities
to support physiotherapy and rehabilitation
Social care and
integrated working
•
Space multidisciplinary working and assessment
Mental Health
•
Assessment & liaison
Specialist services
•
Renal (provided by Imperial)
1
This wording and services are based on the Urgent and Emergency Care work led by Bruce Keogh. The final wording for
the A&E at Ealing may differ following further engagement
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Service
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Key components
•
•
Chemotherapy (provided by Imperial)
Ophthalmology (provided by Moorfields)
Active rehabilitation
beds
•
6 week rehabilitation programme delivered by a multidisciplinary
team requiring diagnostics, therapies, access to specialist opinion
from Consultants and GPs
Post-surgical
rehabilitation beds
•
Post-operative surgical rehabilitation requiring nursing care,
therapy services, diagnostics & access to specialist opinion from
Consultants
Transition beds
•
Nursing care for those waiting for transfer to other settings of
care
Step Up beds
•
Observation, assessment, elective preparation and rehabilitation
to patients.
Palliative care beds
•
Palliative care including last 7 days beds. The current intention is
to deliver from existing meadow house site, subject to options
appraisal on location of Local Hospital on the site.
Diagnostics &
Pharmacy
Diagnostics
•
•
•
•
X Ray, CT, MRI, Ultrasound
Phlebotomy
Near patient testing
Pharmacy
Education &
wellbeing
21 Century Care
Academy
•
The 21st Century Care Academy will provide the core training to
both professionals, patients and carers that is needed to deliver
integrated care at scale and at pace across North West London.
Community Zone
•
•
•
•
•
•
•
Community signposting service
Volunteer coordination service
Patient buddying service
Flexible patient meeting spaces
Expert patient programme
Academic zone
Patient education centre
Retail Space
•
•
•
Cafe
Shops
Pharmacy
Transitional and
rehabilitative care
st
1.4 Workforce
The development of the Local Hospital workforce will reflect its role at the heart of the local
community, working across organisational boundaries to connect services around the needs of
patients. There will be a core of staff based on-site, complemented by a wider group who are
connected closely with those delivering primary and community-based care.
To support this, the workforce model will embrace flexible (including 7-day) working and opportunities
for new and re-designed roles.
The workforce design will depend on the agreed service specifications and activity profiles for the
Health and Wellbeing Centre and Local Hospital respectively. However the ambition for the future
workforce across the different care settings will be of collaborative and multi-disciplinary team
working to deliver holistic care and services. There will be full engagement with staff, skills
assessment and work with Health Education England throughout the design process.
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2 Introduction
Summary:
•
This document is to help inform service figures and how they fit for Ealing
•
Work based on this document will likely include further development of detailed service
specifications and detailed architectural drawings
What this means for patients:
•
The development of the Local Hospital and the services has been developed in-line with the
extensive patient and public engagement undertaken to support this work
•
This should mean services are patient centric with the experience of the service user at the
core of the design
The purpose of this draft is fourfold:
1.
Informs decision making by the clinical commissioners on the form and function of a Local
Hospital
2.
Supports the engagement and testing of requirements with co-commissioners, providers,
service users their families, carers & communities so they can continue to contribute to the
design
3.
Directly informs the development of an Outline and Full Business Case for future investment
4.
Informs the development of business models that will shape the commercial and value
proposition for this Local Hospital
This document builds on the work completed by the SaHF programme to provide a blueprint for
commissioners to make future decisions regarding the services provided by the Local Hospital and
how they should be delivered in order to achieve the strategic vision of the CCGs.
Table 2:1 – What this document does and does not do
This document sets out:
What it doesn’t do:
Local Hospital model and core functions
Define new pathways
Services and delivery models provided by the Local
Hospital
Define the change management steps to deliver the LH
vision
Requirements to achieve this new model including estates
and workforce requirements
Deliver new pathways of care without the changes to
workforce, estate and out of hospital capacity development
Cost and affordability of the LH specification
Address transport issues as a result of the movement of
care
Provide a Local Hospital that facilitates a patient centric
approach to health & care
Local Hospital contribution to potential savings in the
borough of Ealing
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3 Developing a service user centric Local Hospital model
Summary:
•
The Local Hospital is a centre for driving better outcomes across the local health and care
economy
•
The user experience will need to be at the core of the design of the Local Hospital to ensure
that it delivers the best possible care
What this means for patients:
•
Development of services at and around the Local Hospital will be centred on those that will
benefit most from them
•
By being focused on service users, rather than administrative boundaries, the Local Hospital
will deliver better outcomes at the same time as reducing the cost of care
3.1 Working with service users
Ealing CCG has made an on-going commitment to capturing public feedback and patient
experiences. This information is gathered through a number of conduits, including public stakeholder
meetings, the four local community networks, local voluntary sector forums, partnership boards, a
range of patient and carer-led groups, Healthwatch, complaints, Patient Participation Groups at local
GP practices, and via patient representatives.
Community transport, interpreting services and support for carers have been frequently raised
through our PPE work.
Patient feedback and research shows that patients expect a health system that delivers better
quality, more accessible and more co-ordinated healthcare in and out of hospital.
Patients have told us what they want from all out of hospital services and from primary care their
feedback is important in building our plans to deliver out of hospital care.
A range of engagement activities have taken place to support the development of our Out of Hospital
Strategy and Specification for the Local Hospital. The key events and findings are set out below and
these themes have been addressed throughout the document.
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Figure 3:1 – Summary of engagement events to develop the OOH Strategy and Local Hospital Specification
Patient feedback and research shows that patients expect a health system that delivers better
quality, more accessible and more co-ordinated healthcare in and out of hospital. Patients have told
us what they want from all out of hospital services and from primary care their feedback is important
in building our plans to deliver out of hospital care.
3.2 What patients have told us about our current services
From our engagement with patients in Ealing, we know that some expectations of patients include:
•
•
•
•
•
•
Being able to access GPs appropriately for both urgent and routine appointments.
Improved range of diagnosis and treatment available in primary care, reducing the need for
secondary care services
Improved direct access for repeat diagnostics
Clear information on how they can access care in different settings
Care providers working together to co-ordinate patients’ care, so patients do no need to repeat
themselves
Clear discharge plan and arrangement of care post-discharge
3.3 Patient expectations from primary care
Between October and December 2012, we conducted focused research into the priorities of patients
across NW London to help understand what they expect of primary care. A survey of 1,040 patients
identified ten priorities, which can be grouped into three domains:
•
•
•
Improved quality and reduced variation: Patient priorities included having access to appropriate
appointment times, skilled GPs, compassionate staff and consistently good services.
Better integrated services: Patients prioritised smooth and co-ordinated pathways, with access
to specialists and a good range of tests and services. A continuing, trusted relationship with
their registered GP was at the centre of this.
Flexible access: Patients expect to easily reach someone on the phone and get an emergency
appointment when they need one.
The figure below sets out the findings of this survey which have influenced the model of care adopted
for services for Health and Wellbeing Centres and the Local Hospital.
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Figure 3:2 – Patient expectations from primary care
Source: SaHF DMBC, Volume 1
3.4 Patient expectations as a service user
National work has shown that patients expect all care to be better integrated and co-ordinated.
National Voices, a coalition of health and social care charities in England, has defined good coordinated care from the perspective of the service user as:
“I can plan my care with people who work together to understand me and my carer(s), allow me
control, and bring together services to achieve the outcomes important to me”
Central to this are patients setting their own goals and outcomes, shared decision-making, effective
transitions between services, good communication across the system, information sharing, and care
planning. This definition has been adopted by NHS England, Public Health England, Monitor and
local authority bodies, and must inform everything we do.
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4 Context for the Local Hospital
Summary
•
SaHF set out a vision of for transformed care across North West London which would provide
safe and sustainable care to the patients and public on an on-going basis
•
Core to the proposals was the development of Local Hospitals at Ealing and Charing Cross
•
The Local Hospital will play an important role in supporting the change in the care that will be
delivered across North West London, which will address some of the challenging issues
currently faced by existing service users
What this means for patients
•
Safe and sustainable care in North West London
4.1 Context of Shaping a Healthier Future Programme
The Shaping a Healthier Future (SaHF) programme sets out a of radical, interdependent change to
improve NHS services for residents of North West (NW) London. The programme was established in
November 2011, covering many of the services currently commissioned by the eight CCGs 2 in NW
London: Brent, Ealing, Hammersmith & Fulham, Harrow, Hillingdon, Hounslow, Kensington &
Chelsea, and Westminster. The primary aim of the programme – to address a number of challenges
being faced by the NHS across NW London, including the demands of an increasing and ageing
population.
The programme is based upon four core principles which are underpinned by the Secretary of State’s
four tests for reconfigurations. The principles are that the programme should be:
•
•
•
•
Clinically led and supported by GP commissioners
Informed by engagement with the public, patients and local authorities
Incorporate a robust and transparent process underpinned by a sound clinical evidence base
Consistent with current and prospective patient choice
Since 2011, the SaHF programme developed and consulted on wide range of proposals looking at
changing the way care is delivered in NW London, culminating in the Decision Making Business
Case. On 19 February 2013, the Joint Committee of Primary Care Trusts (JCPCT) in NW London,
Wandsworth, Camden and Richmond agreed to proceed with the recommendations presented within
the DMBC. The changes focus on centralising specialist services which people need when they are
seriously ill, localising the most common services people need for everyday illnesses and injuries,
and integrate all of these services with others such as social care. In particular they agreed:
•
•
•
•
•
•
•
2
To adopt the NW London acute and out of hospital standards, service models and clinical
speciality interdependencies for major, local, elective and specialist hospitals
To adopt the model of care based on five major hospitals
That Hillingdon, Northwick Park, West Middlesex, St Mary’s and Chelsea & Westminster
hospitals should be major hospitals
That Ealing hospital should be a Local Hospital
That Charing Cross hospital should be a Local Hospital
That Hammersmith hospital should be a local and specialist hospital
That Central Middlesex hospital should be a local and elective hospital
CCGs replaced PCTs in April 2013 as per the Health and Social Care Act
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•
•
•
•
•
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To move the Hyper Acute Stroke Unit from Charing Cross to St Mary’s
To move the Western Eye hospital to St Mary’s
To coordinate implementation of out of hospital strategies in conjunction with the above
changes
To recommend that Hammersmith & Fulham CCG (Clinical Commissioning Group) work with
stakeholders to develop a business case for an enhanced range of services on the Charing
Cross site
To recommend that Ealing CCG work with stakeholders to develop a business case for an
enhanced range of services on the Ealing site
Since February 2013, a significant programme of work has been underway to manage the delivery of
the recommendations. This document focuses on the development of a Local Hospital at Ealing and
sets out the proposed service model for the hospital. This work has been supported by the overall
SaHF governance process, outlined in Appendix 1.
4.2 The case for a Local Hospital
As highlighted, there are significant pressures on the existing delivery of health and care both within
the borough and system wide, which need to be addressed to ensure improvements in service
quality, delivery and a viable and sustainable service for the future. As part of the overall changes
proposed to the NW London Health system, the development of a Local Hospital within Ealing will act
as a platform to support and drive the necessary changes.
The Local Hospital will act as an integral part of the system providing services focused towards
holistic patient centred care that responds to the physical, social and mental health needs of the
community. In practice, this means local patients, patient groups, the voluntary sector, the local
council including the Health and Wellbeing Board, and local clinicians will be involved in developing
and running the Local Hospital. Without this change the system will continue to be both unaffordable
and unable to meet the needs of patients.
4.3 Improving the experience of patients
A large part of the role of the Local Hospital will be to improve patient experience. Understanding
patient experience is a key part of helping to understand the role that the Local Hospital will play in
improving patient experience. This understanding of patient experiences have shaped the
development of the clinical model for the Local Hospital services.
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Figure 4:1 - Patient experience: today
Table 4:1 – Patient experience: in the future
Activity
Difference in outcome
Following her fall, Geet’s hip surgery would take place at different
location (not at Ealing Hospital)
Negative outcome: The distance and travel make it
harder for family to visit and help with bedside care and
language translation. Geet and her family feel more
stressed.
Her care before and after surgery would be managed at the Local
Hospital
Rather than Clayponds, the LH is more suitable
environment for rehabilitation and family and
community integration, leading to increased confidence
and quicker recovery
A health trainer would work with Geet and her family to build
confidence and train them towards independence; integrated
health and social care team enable Geet to transition home
quicker, without feeling like she is risking her health or financial
situation (she is currently worried about having to pay for home
care and therefore opts to stay in Clayponds longer than
necessary)
Rather than spending 4 months in hospital and fretting
over discharge, the LH offers reassurance and flexible
discharge arrangement with integrated health social
care
At home, Geet and her family are supported to feel confident
about how to access help 24/7; they receive home visits from
physiotherapist and can access advice by telephone
Quicker recovery, greater independence and quality of
life
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Activity
Difference in outcome
A volunteer car scheme coordinated at the LH support Geet to
access the LH for check ups
Greater access to care
Geet’s relationship with her health trainer inspires Geet to
coordinate preventative activity at the temple, such as Falls, Flu
jabs and health awareness
Greater trust and networks of support (knowing who to
call) between informal network and health system
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5 Role of Ealing Local Hospital
Summary
•
The Local Hospital will be the catalyst for change in the way that health and care is delivered
in Ealing
•
The Local Hospital will be at the centre of the community and support improved access to
services with better more efficient and effective outcomes for patients
What this means for patients
•
Patients in Ealing will receive healthcare in a local setting
•
Patients supported to stay out of hospital
•
Patients will receive care that is more joined up
5.1 Introduction
The reconfiguration of services across NW London has created the opportunity to re-think the way
health and care services are delivered in the 21st Century. The new model of care aims to deliver
better outcomes and a higher quality of life for patients by providing holistic, integrated care closer to
home, making greater use of community assets and empowering and enabling patients and carers to
better manage their health.
We want to provide care as close to home as possible so that people can get easier and earlier
access to care. To achieve this will deliver health and care services from a number of different
settings that will be located across the borough. To achieve our vision and goals for out of hospital
care, services will be provided from a number of settings across the borough. Each setting will
provide a range of services that will allow residents across Ealing to access the full range of health
and care support.
In the future, more services, particularly for planned care, will be delivered from out of hospital
settings. The diagram below shows that the majority of support will be delivered in an out of hospital
setting. This is supported by the acute and tertiary care settings which will provide support to those
patients who are most ill.
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To achieve this Out-of-Hospital Services within Ealing will be delivered at the settings described in
the graphic below. Each setting plays clear role in the delivery of health and care in Ealing:
•
Some services can be provided in patients’ homes, for example through nursing
care or telephone support. Services like tele-care enable people living with long
term conditions to live more independently at home for longer.
•
Patients will continue to be registered with their GP and use them as their
main point of access to the health system.
GP practices will continue to deliver the full range of core services and will
offer a variety of systems for walk-in access, telephone triage, same day and prebooked appointments.
Where appropriate GP practices will also provide a range of services including
procedures such as minor surgery. GPs will also have access to services
commissioned on a borough wide basis in order to reduce variability and
achieve value for money such as access to pathology services.
Home
•
GP
Practice
•
•
•
Network
•
•
Health and
Wellbeing
Centre
•
•
•
Local
Hospital
•
•
GP Practices across Ealing are structured into seven health networks covering
populations between 50,000 and 70,000 each (Appendix 2).
By working in health networks we will be able to offer a wide range of Out of
Hospital Services in each area. These services will be delivered in a number of
local settings within a network, including GP surgeries, however they will not be
provided by all GP surgeries. This means that patients may receive care from a
different location than their registered practice.
GP networks are central to collaborative and integrated community-based
services. To support network development further and faster we will appoint a
network relationship manager for each of the localities
Health and Wellbeing Centres will enable and support the delivery of a wider range
of services locally. It will achieve this by:
− Localising the most common services people need for everyday illnesses
and injuries
− Integrating and joining-up clinical services with others such as social care
to intervene earlier along the patient pathway and reduce hospital admissions
over the longer term
− Centralising services currently delivered locally, where access allows,
achieving economies of scale.
− Providing the appropriate infrastructure so that some services currently
delivered in hospital can be delivered locally.
Health and Wellbeing Centres will include a range of services including out-patient
appointments, diagnostic and rehabilitation services.
Shaping a Healthier Future agreed that Ealing Hospital will become a Local
Hospital from 2017 meaning that it will provide a different range of services
than at present.
The Local Hospital will act as an intermediary and point of transition between
primary and community care settings and specialist and acute care settings.
As such the Local Hospital will form part of the wider Out of Hospital service
provision and will be interconnected with GP practices and other providers.
The Local Hospital will also act as a Health and Wellbeing Centre. As a result
patients will also be able access services delivered from the Hospital at the Health
and Wellbeing Centres across the borough. In addition the Local Hospital will
also provide a greater range of diagnostics and services in order to realise
value for money.
Services specific to the Local Hospital are included in the Local Hospital
specification and are therefore not set out in this document
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This proposed Local Hospital has been designed around the needs of service users and, in
particular, those groups who are the highest users of hospital services in NW London. These will
reflect the whole systems approach for NW London and ensure that services are designed in the
most appropriate way taking into consideration medical advancements, latest technology uses,
clinical guidance, changes in demographic needs and the realisation of new pathways of care.
The intention is that the Local Hospitals will become an integral part of the local community. In
practice, this means local patients, patient groups, the voluntary sector, the local council including the
Health and Wellbeing Board, and local clinicians will be involved in developing and running the Local
Hospital.
Achieving this will need a range of skills that are broader than those currently available in acute. It is
expected that multiple providers, across the health and care sector will be needed to operate the
ranged of services to provides from the Local Hospital. Commissioners will tender for these services
and will assess proposals on how the provider will involve service users, their families, carers and
communities in the ongoing design on the Local Hospital; development and monitoring of key
performance indicators; involvement in improvement projects; and the running of services.
Below in figure 5:1 illustrates the positioning of the Local Hospital in the delivery of health and care in
Ealing and how it is a key influencer in the design of an integrated system of care.
Figure 5:1 – The role of the Local Hospital within Ealing
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5.2 Patient-centred principles for a Local Hospital
Through engagement with patients, residents and
health and care professionals eight principles for
the Local Hospital have been developed.
These principles underpin the development of the
service model and will be reflected in the delivery
of services.
The detail of these principles are set out in more
detail below. Local Hospital services and
environment should be designed to:
Support patient to seamlessly move between hospital and community care;
primary and secondary care; care provided in healthcare settings and
healthcare provided at home.
Create networks of carers – both formal and informal – and professionals, so
that the needs, aspirations and assets of patients and carers are
communicated and aligned to health and care provision.
Help people plan their own care across services in a flexible and responsive
way, by connecting services that support medical, social and emotional
wellbeing.
Actively build people’s confidence and capabilities to manage their own
health and care where appropriate.
Reduces barriers to accessing care, whether at the Local Hospital, in other
care settings or in people’s homes.
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Ensure that patients are at the heart of decision-making about their own care,
and involved in the planning and design of local health and care services.
Enhance volunteer capacity and leverage the role of volunteers in services;
facilitate more peer support and make the most of existing community and
voluntary sector services.
Drive high quality of care.
5.3 New models to deliver 21st century care
The whole systems work is developing insight on how best to meet the needs of a richly diverse
population in NW London. Figure 5.2 illustrates the current thinking in population segmentation that
will be used to design all aspects of care in NW London including in the Local Hospital in Ealing.
Figure 5:2 – Whole systems patient segmentations
The engagement undertaken in the early design of the Local Hospital during the Autumn of 2013 with
service users, carers, voluntary organisations, community leaders and clinicians has led to a number
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of strategic decisions on the principles and innovative care models that are best developed and
applied to deliver the range of services that the Local Hospital has to offer. Below summarises these
strategic decision points and the following pages expands each in more detail.
The Local Hospital has a central role in delivering
21st Century care in NW London:
The Local Hospital supports the wider reconfiguration of health and care services across
NW London and enables the CCGs to achieve their
vision to localise, centralise and integrate services.
The primary role of the Local Hospital is to act as
an intermediary and point of transition between
primary and community care settings and specialist
and specialist acute settings.
Multifunctional service to meet the needs of
patients, carers and clinicians
To enable the Local Hospital to meet the needs of
patients, carers and clinicians it will provide a range
of health and care functions. There are five core
functions under which additional functions and
services are aligned.
Model to enable innovative service delivery
The functions of the Local Hospital will enable
innovative service delivery models to be
commissioned. These models will reflect the
principles of a Local Hospital, support delivery of
services across the borough and enable services
that are both clinically viable and affordable.
The Local Hospital is central to the wider reconfiguration of health and care services across NW
London and enables the CCGs to achieve their vision to localise, centralise and integrate services. It
also delivers against the principles for the Local Hospital set out in section 5.2.
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To achieve this, the Local Hospital will become part of a seamless health and care system by
developing strong links with both Out of Hospital and Secondary care services. This will enable the
Local Hospital to act as a virtual hub to maintain a network of diverse health and care functions. This
hub will aim to drive the effectiveness of preventative care, increase access to care and early
intervention and enhance the effectiveness of rehabilitation and recovery after planned and
unplanned treatment.
Figure 5:3 – The role of the Local Hospital within NW London
The Local Hospital, as part of wider Out of Hospital care provision, acts as an effective point of
transition between primary, social and community care settings and specialist and acute care
settings, as illustrated in Figure [5.3]. This is enabled by the Local Hospital providing a set health and
care functions that integrate local primary, community and voluntary sector (VCS) services and out of
hours services. It also facilitates access to better, local care to patients who need specialist and
acute care, helping to minimise unnecessary admissions and enable early discharge.
The Local Hospital sits firmly within Out of Hospital care settings increasing wellbeing, early
intervention and reduction in acute admittance. It also partly overlaps with Secondary and Tertiary
Care settings through its role of increasing the effectiveness of rehabilitation and sustained recovery
of patients after planned and unplanned admission.
The Local Hospital will also act as the home for the local clinical community – a place for education
and training, for continuing professional development, for clinicians and other professionals to come
together to review and improve patient care. This will fundamentally drive the integration and coordination of services.
5.4 Role and Benefits of the Local Hospital
The Local Hospital has a central role in the provision of health and care services across NW London
and in supporting the vision set by clinicians.
The Shaping a Healthier Future programme of change has identified a number of benefits for
patients, carers and clinicians. By fulfilling the role set out above the Local Hospital will be able to
support the realisation of these system-wide benefits. In addition, through further engagement with
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patients and clinicians two additional benefits have been identified; Increased opportunities for
patients and families to volunteer and, improved health and wellbeing across the borough.
The key benefits delivered by the Local Hospital are:
•
•
•
•
•
•
•
•
•
Improved patient satisfaction, patient experience and confidence in treatment
Improved carer satisfaction and experience
Reduced morbidity rates
Reduced admission and readmission rates
Improved clinical outcomes
Improved multi-disciplinary approach to care
Increased confidence for patients regarding their treatment and support
Increased opportunities for patients and families to volunteer
Improved health and wellbeing across the borough
Table 5:1 sets out the role of the Local Hospital and links them to the delivery of these benefits and
potential measures
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Table 5:1 – Role and benefits of the Local Hospital
Vision
Role of the Local Hospital
High-level Benefits set out
in the DMBC
Key Benefits (set out in
DMBC)
Measures
Localising
•
•
•
Improved patient
satisfaction, patient
experience and confidence
in treatment
•
Patient satisfaction rating
•
Improved carer
satisfaction and
experience
•
Carer satisfaction rating
•
Reduced morbidity rates
•
General morbidity rates
•
Reduced admission and
readmission rates
•
Admission and readmission rates
•
Improved clinical
outcomes
•
Measures to be developed for: COPD,
Diabetes, Care of Elderly and CHD
•
Improved multi-disciplinary
approach to care
•
Staff view of Multi-Disciplinary working to
include social care and nursing home
providers
Demonstration with formal integrated
working with social care, 24/7
•
•
•
•
Centralising
•
•
•
Integrating
•
•
•
Provide a range of health and care
functions – including outpatients and
diagnostics – based on the needs of the
local population meaning that patients can
receive care locally
Support wider OOH service delivery by
supporting the co-ordination of a range of
services delivered across the borough
Provide access to specialist opinion in a
local setting
Support patients, particularly those with
LTC, to access, coordinate and proactively
manage their own care
Focus on those patients who are most at
risk of becoming ill the Local Hospital can
support keep people in their homes and
communities
Act as a link between out of hospital and
acute settings through effective
assessment and rehabilitation
Reduce the pressure placed on centralised
services by managing patients out of
hospital and providing an effective triage for
urgent and emergency care needs
Enable the equitable distribution of
workforce across NWL allowing specialist
healthcare professionals to deliver services
in the most appropriate setting as well as
further develop their skills and capabilities.
Support the integration of services across
Ealing by providing co-ordination, access
and space for multi-agency working
Facilitate the role of the voluntary and
community sector in the delivery of health
and care services
Work in new and integrated ways with other
clinicians it will be able to improve the
experience of patients using the service
Ealing Local Hospital Design Guide draft v1.0
•
•
•
Increased ability to take
control of their own
health conditions
Reduced complications
and poor outcomes for
people with LTC by
providing more
coordinated care and
specialist services in
the community
Less time spent in
hospital as services are
provided in a broader
range of settings
Prevent deterioration in
health and reduce
admissions to hospital
through delivering
coordinated care plans
and improved multidisciplinary support
•
•
Increased confidence for
patients regarding their
treatment and support
•
•
Reductions in outpatients, district nurse
visits etc,, for people with LTCs. AND, data
on whether people repeat 6 week reenablement programmes
Number of unscheduled acute admissions
•
Increased opportunities for
patients and families to
volunteer
•
Number of volunteers
•
Improved health and
wellbeing across the
borough
•
•
Reduction in length of stay
Reduction in number of unscheduled acute
admissions by patients identified with a
LTC
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6 Service provision
Summary
•
There are a number of core functions of the Local Hospital:
−
Primary care services (GP practice)
−
Ealing Local Hospital A&E
−
Care assessment, planning and coordination
−
Care delivery
−
Transitional and rehabilitation care
−
Education and wellbeing
•
Services will deliver holistic patient centred care by addressing the patient’s physical, mental
and social care needs
•
New models of care are being explored for these services to improve patient self
determination, self management and independence
•
The services provided from the Local Hospital will help to prevent acute admissions, improve
integration between health, social and mental health services, and improve discharge from
acute
What this means for patients
•
Reduced fragmentation between services
•
Integration of services
6.1 Introduction
This section sets out a short description of each of the key services that will be provided from the
Local Hospital covering: overview of the service, activity, size within the Local Hospital and the
workforce required to deliver the service.
This section follows the structure below:
•
•
•
•
•
•
•
•
Primary care services through a GP practice
Ealing Local Hospital A&E
Care assessment, planning and coordination
Care delivery
Transitional and rehabilitative care
Diagnostics and pharmacy
Education and wellbeing
Retail space
The diagram below sets out the overview of the pathways and referral processes into and out of the
Local Hospital.
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Figure 6:1 – Local Hospital functions
6.2 Services to be provided from Local Hospital
Table 6:1 – Overview of services delivered from the Local Hospital
Category
Service
Key components
Primary care led
services
GP Practice
•
•
•
•
GP appointments
Nurse appointments
Core GP services
Enhanced services including minor surgery
Urgent and
Emergency Care
Ealing Local Hospital
3
A&E
•
•
•
•
•
•
Minor illness
Minor injury
Mental health liaison
Primary care assessment
Access to Diagnostics (incl. x ray, ultrasound, ECG/Echo tests,
CT, MRI)
Near patient testing
Ambulatory Care unit
•
•
•
•
Possible DVT/Confirmed DVT
Unilateral limb cellulitis
Confirmed PE
Confirmed Unilateral Pleural Effusion
Outpatients/ access
to specialist opinion
•
•
•
•
•
•
•
Cardiology
Dermatology
Diabetes centre of excellence
ENT
Frail & Elderly care centre
Gastroenterology & colorectal
Gynaecology
Care assessment,
coordination and
delivery
3
This wording and services are based on the Urgent and Emergency Care work led by Bruce Keogh. The final wording for
the A&E at Ealing may differ following further engagement
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Category
Service
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Key components
•
•
•
•
•
•
•
•
•
•
•
Transitional and
rehabilitative care
Diagnostics &
Pharmacy
Haematology
Infectious diseases including tuberculosis & hepatitis
Patients with long term conditions including cardiac failure, CVD,
respiratory conditions, cancer
Trauma & orthopaedics including MSK & pain management
Neurology
Paediatrics
Respiratory
Rheumatology
Sexual health
Urology
Vascular
Care coordination
•
Planning patients treatment programme through support to
navigate services across physical health, mental health and
social care services
Therapies
•
Therapy services including physiotherapy, dietetics, occupational
therapy, speech & language. The space will include gym facilities
to support physiotherapy and rehabilitation
Social care and
integrated working
•
Space multidisciplinary working and assessment
Mental Health
•
Assessment & liaison
Specialist services
•
•
•
Renal (provided by Imperial)
Chemotherapy (provided by Imperial)
Ophthalmology (provided by Moorfields)
Active rehabilitation
beds
•
6 week rehabilitation programme delivered by a multidisciplinary
team requiring diagnostics, therapies, access to specialist opinion
from Consultants and GPs
Post-surgical
rehabilitation beds
•
Post-operative surgical rehabilitation requiring nursing care,
therapy services, diagnostics & access to specialist opinion from
Consultants
Transition beds
•
Nursing care for those waiting for transfer to other settings of
care
Step Up beds
•
Observation, assessment, elective preparation and rehabilitation
to patients.
Palliative care beds
•
Palliative care including last 7 days beds. The current intention is
to deliver from existing meadow house site, subject to options
appraisal on location of Local Hospital on the site.
Diagnostics
•
•
•
•
X Ray, CT, MRI, Ultrasound
Phlebotomy
Near patient testing
Pharmacy
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Category
Education &
wellbeing
6.2.1
Service
st
Draft v4.0
Key components
21 Century Care
Academy
•
The 21st Century Care Academy will provide the core training to
both professionals, patients and carers that is needed to deliver
integrated care at scale and at pace across North West London.
Community Zone
•
•
•
•
•
•
•
Community signposting service
Volunteer coordination service
Patient buddying service
Flexible patient meeting spaces
Expert patient programme
Academic zone
Patient education centre
Retail Space
•
•
•
Cafe,
Shops
Pharmacy.
Primary care services: GP Practice
Overview
•
Space for a GP practice will be located on site. While the exact form will be developed in
consultation with NHS England and the LMC it is anticipated that the practice will be an integral
part of the hospital and form part of the fabric of primary care provision within Ealing. The
practice will:
−
−
−
−
−
−
−
•
Deliver core primary care services to a registered list
Be a member of a GP network and Ealing CCG. They will support both the network and
CCG to deliver its plans and priorities for health within Ealing
Support the provision of extended hours (08:00 – 20:00) and will be open 7 days a week
Support the delivery of enhanced services by providing some of these from the LH site
Offer a variety of systems for walk-in access, telephone triage, same day and pre-booked
appointments.
Support the delivery of out of hours care within Ealing
Be an exemplar practice within the borough
The GP on site will have the same access to the full range of services delivered from the local
hospital site as GPs across Ealing, these include:
−
−
−
−
−
−
−
−
Ealing Local Hospital A&E
Direct access diagnostics including imaging and phlebotomy
Access to specialist opinion/outpatients
Mental health teams
Social care services
Care coordinator service
Sexual health services
Specialist training and education activities
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Services
•
The services delivered from the GP on the Local Hospital site will include:
−
Core (essential and additional) services commissioned by NHS England , including:
◦
◦
−
−
−
•
•
Essential: GP consultations, asthma clinics, Chronic obstructive airways disease
clinics, Coronary heart disease clinics, Diabetes clinics
Additional: Cervical cytology screening, Contraceptive services, Child health
surveillance, Maternity services, Certain minor surgery procedures, Vaccinations
and immunisations
Local Enhanced services commissioned by the CCG; through community contracts (from
April 2014:
National Enhance services commissioned nationally
Directed enhanced services commissioned by NHS England
The GP practice will also be expected support the integration of care and will act as the named
point of contact for co-ordinating care for their patients. Whilst not all care or coordination has
to be delivered by individual GPs, the GP’s patient register will be the organising principle that
guides how care is co-ordinated between agencies.
The GP practice will work alongside the Ealing Local Hospital A&E to encourage unregistered
patients to register with the GP site and to use their services as the first point of access with the
health system when required.
Table 6:2 – Primary care services – activity and size
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Primary Care in the Local Hospital:
Patient benefits
•
Extended opening hours including evenings and weekends to improve access
•
Better and more integrated support for those with long-term conditions, such as a base for
MDT’s
•
Access to more services in one location to ensure a more ‘ one stop shop model’ of care
•
Access to care and support will also be available to patients who aren’t registered with the GP
Practice on site
Direction of travel
•
Increasing the accessibility of primary care led services to reduce the reliance on secondary
care
•
Co-location of primary and secondary care to better manage patients in a holistic and longterm way
Next steps
•
Identify GP practices for potential presence on the Local Hospital site
•
Agree Out Patient model for GP services on site
6.2.2
Urgent and Emergency Services
6.2.2.1 Ealing Local Hospital A&E 4
Overview
The Ealing Local Hospital A&E will advise, assess and initiate treatment for people with urgent care
needs, such as minor illnesses and injuries. Suitable people will be managed by the fully integrated
services at the Ealing site. Those needing specialist treatment will be stabilised and transferred to
Major Emergency Centres. Ealing Local Hospital A&E will be closely integrated into the North West
London network of Emergency and Major Emergency Centres.
The scope of the Ealing Local Hospital A&E aligns with the Urgent Care Centre service specification
developed for all NW London UCCs and the findings in Keogh’s review into urgent and emergency
care in England 5.
The urgent care aspect of the Ealing Local Hospital A&E has been defined by the Emergency and
Urgent Care Clinical Implementation and Planning Group. This states that the Urgent Care Centre
will work on the principle that all patients should receive a consistent and rigorous assessment of the
urgency of their need and an appropriate and prompt response.
The aims and intended service outcomes are:
•
The service model is based upon the need to provide improved access to urgent, unplanned
care, while ensuring that the patient’s ongoing healthcare needs are met in the most
appropriate setting within the community or primary care. This may involve streaming patients
4
This wording and services are based on the Urgent and Emergency Care work led by Bruce Keogh. The final wording for
the A&E at Ealing may differ following further engagement
5
NHS England (2013) Transforming urgent and emergency care services in England: Urgent and Emergency Care Review.
Available from: http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf
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•
•
•
•
•
•
Draft v4.0
back into services (e.g. GP practices, community services) via a process of positive redirection.
The Ealing Local Hospital A&E will operate over twenty four hours, seven days a week. It will
act as a single point of access to on-site emergency and urgent care services for walk-in
patients.
The Ealing Local Hospital A&E will integrate with current service provision but will develop the
distinctive culture and approach of a primary care service, with experienced and appropriately
skilled primary care clinicians leading the service, working alongside other healthcare
professionals undertaking assessments and seeing and treating patients.
The Ealing Local Hospital A&E will not constitute a further access point for routine NHS care in
the health economy; neither will it allow duplication of existing services. Patients attending who
do not have urgent care needs will be supported by staff in the centre to access advice and
care from their local community pharmacist, or to make an appointment with their own GP
within the target timescales.
Service providers of the Ealing Local Hospital A&E and the Emergency Department will be
required to work together to ensure integrated and seamless care pathways.
The Ealing Local Hospital A&E should ensure patients receive a consistent and rigorous
assessment of the urgency of their needs and an appropriate and prompt response.
The Ealing Local Hospital A&E Information and Communication Technology (ICT) processes
should be inter-operable with both GP and Trust systems in order to facilitate effective
information sharing.
The main elements of the service will include:
•
•
•
Streaming, registration and initial assessment;
Diagnosis and treatment access to CT & MRI;
Referral and discharge.
The Ealing Local Hospital A&E will be able to refer to the services provided from the Local Hospital
such as frail and elderly care centre, mental health liaison service, ambulatory care for medical
specialties, fracture clinic, care coordination, education and GP practice. The figure below sets out
how patients will experience the Ealing Local Hospital A&E.
Figure 6:2 - Patient experience of the LECC
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6.2.2.2 Ambulatory Care Unit
Overview
The NHS Institute for Innovation & Improvement has identified various emergency clinical
presentations which can be managed in an ambulatory setting, i.e. emergency care without the need
for an in-patient stay.
Such an approach has been employed in various trusts across the UK reducing bed occupancy,
length of stay and improving quality of care. This could will include the following services:
•
•
•
•
Possible DVT / Confirmed DVT
Unilateral limb cellulitis
Confirmed Pulmonary Embolism
Confirmed Unilateral Pleural Effusion
This service will support the Ealing Local Hospital A&E and prevent admissions to Acute Hospital
Care. It will be required to develop close links to a range of services including the Ealing Local
Hospital A&E, Frail and Elderly service as well as Out of Hospital Services such as the Intermediate
Care and Rapid Response Service.
Table 6:3 – Urgent and Emergency Care – activity and size
Urgent and Emergency Care in the Local Hospital:
Patient benefits
•
Better patient experience through:
−
Enhanced links to one stop shop rapid access to specialist clinics
−
Links to the community zone
−
Attention and focus of dedicated staff with specialist skills focused on minor injury care
to ensure more effective and quicker service
•
Immediate access to 24/7 urgent and emergency care for minor injuries and illnesses
•
Prevents acute admissions
•
Actively reduce future need through referral to onsite education, if required admit to bedded
care and prevention services e.g. DESMOND and DAFNE training for diabetes management
Direction of travel
•
Prevent acute admissions by assessing patients and providing the primary care support to
patients, creating an Ealing Local Hospital A&E that actually prevents acute admissions
•
Prevent acute admissions by providing access for patients with acute aggravated conditions
Next steps
28
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•
6.2.3
Draft v4.0
Develop the pathways of care between mental health, social care, tertiary, secondary and
primary care services through MDT’s focused care delivery.
Care assessment, coordination and delivery
6.2.3.1 Access to specialist opinion/outpatients
Overview
Traditionally care has been delivered in an outpatient setting. The Local Hospital provides an
opportunity to move towards a model that will support patients to make informed decisions about
their health and care needs by accessing health and care professionals in a number of ways in order
to address physical, social and mental health care needs.
A range of models of care for these services are being explored and these are set out below. These
models of care will draw upon other services within the local hospital and clinicians will be able to
refer patients internally as required. The services will be expected to operate 6 days a week and
open for extended hours.
Access to specialist opinion and outpatient services will form an integral and key part of the new
Ealing Hospital. A modern approach to how rooms are laid out and utilised means that many of the
rooms will be multi-purpose which will drive the efficient use of space. A central booking function will
be responsible for the efficient booking of all people into clinic slots, ensuring that waiting times are
low. Reception staff will manage the daily flow of people with the support of 21st century technology
Services
The services listed below may be provided from the Local Hospital:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Cardiology including ECG/ Echo tests & risk assessments
Dermatology including telehealth, phototherapy & minor procedures
Diabetes and Cardiovascular Disease Centre of Excellence
ENT
Frail & Elderly care centre
Gynaecology
Haematology including anticoagulant & therapeutic e.g. sickle cell
Infectious diseases including tuberculosis & hepatitis
Patients with long term conditions including cardiac failure, CVD, respiratory conditions, cancer
Mental health including psychiatric, mental wellbeing & assessment
Trauma & orthopaedics including MSK & pain management
Neurology
Paediatrics
Respiratory including specialist nurse led clinics for COPD, TB, asthma & pulmonary rehab and
assessments for oxygen & nebulisers
Rheumatology including joint injections, podiatry & linking with MSK & diabetes services
Sexual health including GUM, specialised clinics, contraception & HIV
Therapy services including physiotherapy, dietetics, occupational therapy, speech & language
Urology
Vascular
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Potential models of care
There are a number of different models of care that could be adopted by the services offered from
the Local Hospital. The models summarised below are a few key examples that are being
considered.
•
Frail & Elderly care – A dedicated services for frail and elderly patients. This service will focus
on complex patients who have a number of long-term conditions and provide a one-stop-shop
for this cohort of patients. The service will be primarily GP led consultant geriatricians and
include nurses, pharmacists, intermediate care, social care and. To be effective this service
must link with the range of services including patients own GPs who will continue to manage
their co-ordination and the Intermediate Care Service (ICE). The service will have access to the
full range of diagnostics on site.
−
−
−
•
Prevent emergency admissions for frail, elderly patients
Reduce excess bed days
Prevent readmissions from acute and specialist care beds
One stop care – An integrated service of diagnostics, planning and social care assessment
activities developed to support different patient groups and conditions. This would reduce
duplication and allow for rapid multidisciplinary assessment and planning around the patients
who could benefit most. It is designed to identify both clinical issues and opportunities for more
effective care and support for clinical, social and emotional needs. One stop clinics are reliant
on diagnostic services including imaging, and phlebotomy. Potential services that may be
delivered through one stop clinics include:
•
•
•
Cancer
Diabetes
Neurology
•
•
•
Cardiology
Gastroenterology
Ophthalmology
•
•
•
Dermatology
Haematology
Trauma &
Orthopaedics
Diabetes and Cardiovascular Disease Centre of Excellence
The Diabetes and CVD Centre of Excellence will offer advice and support from expert multidisciplinary teams from all fields of medicine. This will ensure diabetics in Ealing receive first class
holistic support and care. The Centre of Excellence will follow the one-stop model of care and will
include the following services:
•
•
•
•
•
•
•
•
Complex type 1&2 assessment, annual reviews, treatment, education & checkups
Investment in new technologies for self-management, monitoring and progression
Psychiatric assessment & support
Paediatric & young adult diabetes services
Diabetes and Maternity services
Nutritional support from on-site dietetics services
Complications management: including foot, renal, eye & neurological disorders
Group and private self-management education in 21st Century Care Academy. DESMOND &
DAFNE for all
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•
Joined up assessment bundles – The Local Hospital will be part of the pathway of care for key
patient groups. Visiting the Local Hospital for planned outpatient services will experience a
joined up approach that puts them at the centre of care. This would mean more efficient, quick
access to services – especially between diagnostics and treatment; more tailored personalised
care; and greater control and choice. Key element of this include: access to specialist opinion /
outpatients; diagnostics.
•
Enhanced elective preparation – The Local Hospital plays a vital role in pre-assessing patients
and planning holistic preparation for the patients who undergo elective treatments. Patients and
their families will be supported to plan their recovery in a holistic way that meets the patients’
clinical, social and emotional needs. This may include working with dieticians, physiotherapists,
occupational therapists, counsellors and social care. Patients will undergo necessary
screenings and diagnostics before treatment.
•
Telehealth and Telemedicine – involves using technology to enable healthcare professionals to
remotely monitor data on certain aspects of a patient’s health. The local hospital and CCG will
consider how best to use technology to support the diagnosis and monitoring of certain
conditions.
Table 6:4 – access to specialist opinion/outpatients - activity and size
Specialist outpatient services
The Local Hospital will support the delivery of specialist services in a local setting closer to people’s
homes. These services will be delivered by specialist Consultants, nurses and allied health
professionals as well as metal health specialists.
They include ambulatory cancer care, renal dialysis and ophthalmology. No new models of care have
been identified for these services. It is assumed that they will use the most clinically appropriate
technology, equipment and workforce to deliver the services, in accordance with national guidelines
from Royal Colleges and NICE.
Table 6:5 - specialist outpatient services - activity and size
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Health and Social Co-ordination
Overview
Patients with complex health and social needs, such as the frail elderly, patients with long term
conditions and frequent users of health and social care services, will benefit from additional support
so that the care they receive from different parts of the system is joined up and co-ordinated.
The local hospital will support the delivery of the vision for whole systems integrated care which is
supported by three principles:
1.
People will be empowered to direct their care and support and to receive the care they need in
their homes or local community.
2.
GPs will be at the centre of organising and coordinating people’s care.
3.
Our systems will enable and not hinder the provision of integrated care.
GPs will be at the centre of organising and coordinating people’s care and will act as the people’s
champion; ensuring people receive high quality integrated care that helps them achieve their own
goals. GPs will work with other providers in integrated networks and will be able to draw upon all the
services and resource they need to meet people’s care goals. Whilst not all care or coordination has
to be delivered by individual GPs, the GP’s patient register will be the organising principle that guides
how care is co-ordinated between agencies.
Care co-ordinators – which are new roles of be commissioned jointly between Health and Social
Care – will be responsible for ensuring that our out of hospital standards relating to care planning and
co-ordination are met. They will ensure that patients always know who to turn to, without having to
worry about which agency is responsible for any particular need, or which budget it might relate to.
While they will be based in our seven care networks, the local hospital will play a role in supporting
them to deliver the level of care required.
The specific workforce for these services will include:
•
•
•
Care navigators (which may be volunteers) will support patients to navigate between services
Health and Social Care Co-ordinators (HSCC) will need to develop relationships and work
closely with a range of professional groups to ensure patients receive joined-up care. The care
co-ordinator role will require knowledge and skills in relation to social care and wider public
services, as well as healthcare.
Health and Social Care Co-ordinators will:
−
−
−
coordinate health and social care packages according to the care plan agreed by the
case manager, individual and carers
support individuals’ main tenance of goal
coordinate early supported discharge from acute to home and on-going care prior to
discharge from rapid response, including liaising with primary care team, individual,
carers and social care
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Table 6:6 - health and social care co-ordination - activity and size
Therapies
The Local Hospital will provide therapy service. These services will be used by both
outpatients and patients using transitional care and rehabilitation. The services include:
•
•
•
•
Physiotherapy
Dietetics
Occupational therapy
speech & language
Table 6:7 - therapies - activity and size
6.2.4.1 Mental health services
Overview
To support the delivery of NW London Mental Health Strategy the Local Hospital will support the
provision of two key services; Psychiatric Liaison and improving adherence to care plans for patients
with Long-Term Conditions and Mental Health Co-morbidities. This will form part of an integrated
service for patients in Ealing.
Psychiatric liaison: These services will improve access to mental health care for patients that are in
bedded care and support other health and care professionals to identify and treat mental health
patients. This will form part of a comprehensive specialist mental health team across hospitals in NW
London to provide 24/7 liaison cover (staff in this service may not located on site 23/7).
Adherence to care plans for patients with long-term conditions and mental health comorbidities (“LTC”): This will provide tailored support to improve patient outcomes. The Local
Hospital will enable integrated delivery models to effectively diagnose and treat the mental health
needs of patients with LTCs. The focus will be on the large group of patients with common mental
illnesses (CMIs) such as anxiety and depression.
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The table below presents the co-incidence of Long Term Conditions for a sample 51,000 patients that
presented at Ealing Hospital in FY11/12 for at least one inpatient episode.
These are separated into those over 65 and under 656. The analysis highlights the prevalence of
mental health issues as part of other Long Terms Conditions presented.
Patients over 65
The table below shows for over 65s in the sample shows that patients presenting with a number of
LTCs also had CVD.
Table 6:8 - Patients over 65 with multiple long term conditions
Patients under 65
The table below shows that for the sample group 69% of patients presenting with Diabetes also had
CVD. Other significant areas of comorbidity are COPD and CVD and Stroke and CVD.
Figure 4.10 Patients under 65 with multiple long term conditions
6
Source: Hospital Episode Statistics, PwC Analysis
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Care Assessment and Coordination in the Local Hospital:
Patient benefits
•
Better transition between diagnostic and treatment
•
More efficient, quick access to services in the Local Hospital and to other health and care
providers
•
More control and choice over care
•
Fewer visits needed and reduced duplication
•
Better, more integrated use of technology
•
Everything together in one accessible place
•
Easier to know where to go
•
More tailored, personal care
•
Local access to most commonly used services
Direction of travel
•
Multidisciplinary teams providing joined up care and assessment of patients, reducing
repeated appointments and duplication
•
More patient involvement and development of services and care planning
Next steps
•
Identify the different models of care for how each speciality could be delivered and develop
commissioning intentions to deliver these. This may require tendering services and developing
multi-provider contracts to reduce the boundaries between care settings
6.2.5
Transitional & rehabilitative care
Overview
The Local Hospital provides a link between community and acute care. One of the ways in which it
will do this is through step up and step down beds. Care will be designed and delivered to meet
patients physical, mental and social care needs, 24 hours a day 7 days a week.
The following models of care are being considered for these beds:
Step-down: Active Rehabilitation Care – Post-treatment, patients will be referred from a specialist or
acute hospital (or internally within the Local Hospital) to be managed by the integrated community
rehabilitation function in the Local Hospital, bringing together a range of services and support in and
out of the Local Hospital.
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Transition: ‘Waiting for’ Care – Multidisciplinary care for patients who cannot be discharged either
because they need rehabilitation, or are waiting for a safe bed and are not appropriate to go home.
The next stage of the patient’s pathway could either be a transfer to another setting of care (including
the patients’ home), rehabilitation or end of life care.
Step-up: Active Prevention Care – The Local Hospital step up beds will provide observation,
assessment, elective preparation and rehabilitation to patients. GPs from within the Ealing Local
Hospital A&E, GP Practices and Health and Wellbeing Centres will be able to admit to these beds. In
addition, the access to specialist opinion/outpatient services may also be able to admit into these
beds for specific services such as Frail and Elderly or for closer management of acute episodes of
long-term conditions such as respiratory failure.
Number of beds
The table below sets out the volume of beds currently estimated from Ealing Local Hospital. For
further detail on the beds including the costs associated see Appendix B.
Table 6:9 – Number of beds at Ealing Local Hospital
Type of bed
Number of beds
Step up – to be commissioned by the CCG to enable the delivery of new pathways of care
31
Step down – Rehabilitation / transfer beds to be commissioned by West Middlesex NHS Trust
15
Step down – Rehabilitation currently provided at Clayponds, to be commissioned by the CCG
36
Palliative care beds – currently provided at Meadow House, to be commissioned by the CCG
20
TOTAL
102
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Table 6:10 - bedded care - activity and size
Transitional Care in the Local Hospital:
Patient benefits
•
Early intervention, diagnosis and treatment
•
Prevention of acute admissions
•
Local and convenient setting
•
Improved self management and independence
•
Real opportunity to regain lost function
•
Focused, therapy and community led care
•
Improving self management and independence
•
Attention and focus of dedicated, highly skilled staff from a range of disciplines e.g.
physiotherapists, speech and language therapists, and occupational therapists
•
Environment that is inclusive of family and support networks
•
Active progression towards health and care goals
•
Reduce Los for admitted patients due to Rehab Model
•
Direction of travel
•
Reduced admissions to secondary care hospitals
•
Improved discharge and rehabilitation from secondary care
Next steps
•
Continue to improve and develop model
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Diagnostics and pharmacy
6.2.6.1 Diagnostics
Overview
A comprehensive range of diagnostic services will be provided from the Local Hospital to support
effective assessment and treatment planning for patients. Services include
•
•
•
ECG
MRI Scan
X-Ray
•
•
•
Blood Pressure Monitoring
Echocardiography
Near patient testing
•
•
CT Scan
Ultrasound Scan
Patients will be referred for diagnostic services from:
•
•
•
•
Ealing Local Hospital A&E
GP practices (including those based outside of the Local Hospital) – GP direct access
Assessment from specialists in outpatient clinics
Step up and step down beds
The close adjacencies and working between these services will support effective utilisation of the
overall Local Hospital estate.
6.2.6.2 Pharmacy
The pharmacy service will provide drugs for inpatients and patients in the Ealing Local Hospital A&E.
This will include providing drugs for patients during their stay and the drugs they require upon
discharge. The pharmacy will not make chemotherapy on site. This is expected to be delivered by the
provider of chemotherapy services. It is anticipated that this pharmacy would be contracted as part of
a hub and spoke model, so that this smaller pharmacy is part of an existing larger contract ensuring
viability.
Table 6:11 - diagnostics and pharmacy - activity and size
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Diagnostics and Pharmacy in the Local Hospital:
Patient benefits
•
More convenient testing times due to extended operating hours
•
More rapid decision making and therefore treatment, leading to confidence in diagnosis and
improved outcomes
•
Near patient testing, telehealth and technology leading to instantaneous results and feedback,
significantly reduced waits for results, increased options e.g. goal directed therapy techniques
•
Reduced need for repeat visits for diagnostic tests
Direction of travel
•
Increasing access to diagnostics and reducing the time patients and clinicians wait for their
results
Next steps
•
Explore contracting requirements for the pharmacy
6.2.6.3 Pathology
There will be a central Pathology service running across North West London and it is envisaged that
there will be a contract incorporating responsive turnaround times for all pathology tests. Therefore,
workforce for this service has not been included
Education and wellbeing
6.2.6.4 21st century learning environment
•
The Local Hospital will support the provision of learning for patients, carers and health and care
professionals.
•
The training will be interdisciplinary and patients will have a core role in designing what
programmes are delivered as well as feeding into the professional training.
•
The Academy will include courses and programmes provided by higher education institutions,
voluntary and community providers as well as NHS organisations.
•
The 21st Century Care Academy aims to develop the capabilities and skills of both healthcare
professionals and patients to deliver integrated and co-ordinated care.
•
The Academy will:
−
−
Empower patients to self-manage by supporting them with targeted and evidence based
training and peer support.
Create networks of health and care professionals through interdisciplinary training and
ongoing professional development.
6.2.6.5 Community zone
The Community Zone would house non-clinical services and activities that support families and
communities to build their social networks, increase wellbeing and better manage their own
conditions. The space would be managed by a central coordinating team who manage a portfolio of
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services relevant to the clinical and community priorities; ensuring the services are vibrant and of
excellent quality. A primary function would be patient and carer enablement, both online and offline –
providing access to information, products, services and support for independent living. Referral
between clinical and non-clinical activities would optimise opportunities for better patient care.
The services that would be delivered in the Community Zone include:
•
•
•
•
•
•
Community signposting service
Volunteer coordination service
Patient buddying service
Flexible patient meeting spaces
Expert patient programme
Peer support networks
The Community Zone would also house providers of complementary services delivered by 3rd sector
or commercial providers, such as carer support, patient advice and liaison pals, peer support groups,
self-management training. It would also include a pharmacy that offers training and counselling
around medication for patients and carers.
Depending on agreements with the local authority, the Community Zone could extend to include
other services that would benefit from co-locating in the LH. These could include learning disability
services, smoking cessation, Citizens Advice Bureau, library, fitness centre, crèche.
The aims of the Community Zone are:
•
•
•
•
•
Reduce overall need by supporting self-management of care
Ensure that a range of dedicated and targeted services and support are delivered from the
Local Hospital for diverse local communities and patient groups
Actively facilitating the growth of networks of patients with lived experience of conditions in
order to increase peer learning opportunities and sustain positive behaviors
Ensure that health and care support actively identifies and engages a patient’s support
resources & assets
Support the use effective use of patient-held health management and monitoring tools and
technology, including patient information and personalised health and care plans
6.2.6.6 Retail space
Within the Local Hospital there will be a retail space that allows for a café, shops and a pharmacy.
This will enhance the experience for patients, carers, family and staff. it will help to create a social
environment and improve access to everyday goods.
Table 6:12 – education and wellbeing – activity and size
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Education and Wellbeing in the Local Hospital:
Patient benefits
•
Opportunities for patients and carers to get involved in volunteering
•
Clear point of entry and exit that people recognise
•
A new landmark building for H&F
•
Convenient parking pick-up and drop-off
•
Help and learning to better self manage conditions
•
A dedicated space to meet, learn and build support networks
•
Clearer connections between clinical mental social environmental determinants of health
•
Friendly and helpful place for advice and signposting
Direction of travel
•
More self-empowerment / education / tools / ideas for residents
Next steps
•
Confirm the operating model for education and wellbeing services
•
Engagement with patients and residents to understand the which services and amenities they
would like to receive
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Appendix A – Process to develop specification
This section outlines the process to arrive at the service model proposed for the Ealing Hospital site.
The process involved:
•
Further engagement (building on the engagement carried out through the development of the
DMBC)
•
Understanding and analysis of the existing baseline for service, demand, supply, workforce and
finance
•
Co-designing, testing and refinement of service models for the hospital with the Trust,
Commissioners and users
•
Assessing the impact in terms of cost, benefits and risks
Engagement
Engagement with a wide variety of key stakeholders was an integral part of the service model
development. Building on the engagement undertaken during the development of the DMBC, wide
scale engagement was undertaken in the initial stages. This consisted of:
•
Large scale public and patient interactive events/session which included the Trust and
commissioners along with other key stakeholder groups
•
Proactive outreach targeted at hard to reach groups, patient representative groups
•
Focus groups conducted with representative cross sections of the local population
•
Drop in sessions – to reach local communities and provide opportunity for those to discuss their
thoughts on the Local Hospital
The aim of this engagement phase was to develop an understanding of the need and requirements
for the future Local Hospital at Ealing. This supported the establishment of shared vision, set of
principles and functions for the Local Hospital (outlined below), which were used to determine and
define the services to be located on the site and the potential new models of care to improve service
quality and delivery in the future.
Understanding the Current Baseline
The engagement phases was supported by significant analysis to develop clear understanding of
existing activity, service demand and supply, estate and workforce within Ealing. This included:
•
Services currently provided on the existing hospital site and likely to be provided on the Local
Hospital site in future (mainly outpatient activity, diagnostic), with consideration given to the
‘alternative proposals’ developed by Commissioners for the Local Hospital at Ealing post
DMBC in conjunction with local people.
•
Services that would change the type of care delivered, such as step-up bedded care to reduced
acute admissions and rehabilitative bedded care and supportive therapies
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•
Services that could be moved from one location to another, such as some community services
to be delivered at the Local Hospital and those which could be delivered in the community
(drawing on the other SaHF work underway, future commissioning intentions)
•
New services that are not currently provided e.g. care coordination and patient education; and
•
New models of care or ways of delivering the services to help reduce or redirect activity to a
more appropriate setting e.g. closer to the patients home
Design, testing and refining
Based on the outputs and insights drawn from the engagement phase and the information gathered
to understand the baseline, an initial service model to be delivered at the Local Hospital was
developed. This service model looked to:
•
Ensure that services are designed in the most appropriate way taking into consideration the
medical advancements, latest technology uses, clinical guidance, changes in demographic
needs and the realisation of QIPP schemes.
•
Reflected the impact of changing care delivery within other care settings (e.g. Health and
Wellbeing Centre, whole systems work, acute care delivery)
•
Drew on evidence to ensure the most effective and efficient modes of service delivery and
ability for different parts of the health system to provide; and
•
In doing all of the above, aim to configure services to improve overall patient outcomes
This service model was tested and refined jointly with the Trust and Commissioners through a series
of focused meetings outlined below, to arrive at an agreed service model presented within this
document. These meetings also supported the assumptions around way in which services should be
delivered within the local hospital setting but also across and within the acute and community settings
ensuring interdependencies are accounted for.
•
Trust Clinical Meetings: these consisted of clinical leads for a variety of services. These
meetings were used to support the development, interaction and ways of working for the
proposed services.
•
CCG Operational Meetings: Weekly discussion meetings with Ealing CCG, set up as part of
the overall SaHF governance arrangements, where the service proposals were discussed and
refined
•
CCG Zone Meetings: Regular meetings consisting of the CCG, Trust and other stakeholders
to discuss the SaHF transformation programme for the Ealing Zone in totality. These meetings
allowed for the proposals to be tested and refined more widely with an extended group
•
The Patient & Public Representative Group (PPRG) brings together patient and carer
representatives from across NW London to help the Shaping a healthier future programme to
ensure it has considered and responded to the needs of patients, carers and the public during
the implementation of changes. The PPRG has helped shape our approach to patient and
public engagement and overall service model.
•
Ad hoc meetings: Additional meetings attended by the CCG and the Trust were set up on an
ad hoc basis to support the refinement of the clinical service model.
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Assessing the impact
The service model was used to inform the requirements for the Local Hospitals in relation to estates,
workforce and cost, income generation to assess the financial impact on both the Trust and also on
commissioners, including how this compares with the DMBC assessment. This was continually
refined in line with the process to develop the clinical service model.
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Appendix B – Detailed case for change
How the Local Hospital fits into the case for change across NW London
This section provides an overview of the case for change that underpinned the recommendations
presented to the JCPCT. The case for change was developed by local clinicians with involvement
from providers, CCGs and representatives of patient groups and the public.
This section provides an overview of the case for change – including the regional, local, clinical and
financial change. The full document can be found in Appendix D (Volume 3) of the Decision Making
Business Case on the Shaping a Healthier Future website 7.
Overview of the Regional Case for Change
The NHS in NW London is facing a number of pressures and challenges. There is increased demand
caused by the ageing population and increased prevalence of long term conditions and comorbidities, for example:
•
The population of NW London has risen to 2 million
•
Life expectancy is now 80 years for men and 84.5 years for women. This is an increase
from 76.8 years for men and 81.9 years for women a decade ago
•
Some 300,000 in NW London – nearly one in six – people of all ages – have one of the
following five long-term conditions: diabetes, asthma, coronary heart disease (CHD),
chronic obstructive pulmonary disease (COPD), and cystic fibrosis disease (CFD)
There are also unacceptable variations in the quality of care provided, evidenced by higher mortality
rates for patients who are admitted in hospital at night or during the weekend. Whilst the movement
to reconfigure and centralise key services in London, such as stroke and major trauma care which
has resulted in improved patient outcomes, more is required. Improvements in preventing ill health
and improve access to, GP and community care is needed to drive overall quality and satisfaction. To
achieve this, significant operational changes rather than incremental, individually devised approaches
are needed.
Local Case for Change
Ealing’s demographics are changing and, as a result, the health and care system needs to respond:
•
•
•
•
•
•
Ealing’s population: set to rise to 372,000 by 2020
A predicted increase of 48% in over-85s
A quarter of our population is aged under 20
High proportion of children living in poverty
Significantly increasing demands on and need for carers of children and older people
Increasing prevalence of long term conditions in deprived areas
7
http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/SaHF%20DMBC%20Volume%203%20Edition%2
01.pdf
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In addition to the demographic challenges, Ealing has a number of specific health challenges which
include:
•
•
•
•
The main causes of death in the borough are; Cardiovascular disease – 31% of all deaths,
Cancers – 30% and Respiratory disease – 14%
High rates of emergency admissions for heart attacks, strokes, and mental health problems
High prevalence of diabetes – 20,000 patients diagnosed, set to double in the next ten years
High rates of substance misuse and alcohol-related hospital admissions
Appendix B presents the Health Profile for Ealing for 2013 as developed by the Health Observatory.
Map of deprivation (EALING)
Age profile of population
The latest ONS sub-national population projections (2011 Census-based) suggest that, by 2020,
Ealing’s population will reach 372,400, with most of the increase due to a 14.8% rise in the number of
people between 0 and 14 years old. There will be a 19.5% rise in the numbers of over 65 years of
age, whereas the number of over 85s is expected to rise by 48%.
Population
Year
0-14
15-24
25-64
65+
All ages
2011
65.1
43.0
194.8
36.5
339.3
2012
74.7
39.3
214.9
43.6
372.4
Source: Office of National Statistics (ONS) 2011 census-based sub national population projections
Whilst this highlights that people are living longer, this does not necessarily mean healthier lives. The
increasing ageing population will place significant demand for health and care services within the
borough and the pressure on the system as whole. A change in the focus of health and care delivery
is required.
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The Clinical Case for Change
The demands on the NHS in NW London are changing
As indicated the population of NW London is growing and life expectancy is improving. Overall the
NW London population is forecast to increase by approximately 141,000 people (7%) growing from
circa 2 million to circa 2.15 million over the period to 2018.
Life expectancy in NW London is now 80 years for men and 84.5 years for women; this is a three
year increase from 10 years ago and is particularly due to early diagnosis and improved treatments
resulting in fewer people dying prematurely from diseases such as cancer, heart disease and
strokes. This is likely to result in an increase in the number of patients with longterm conditions such
as diabetes, heart disease and breathing difficulties. In NW London some 300,000 people, nearly one
in six, of people all ages have one of the following five long-term conditions: diabetes, asthma,
coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), and congestive heart
failure.
Fortunately, the ability to prevent, diagnose and treat medical conditions is constantly improving.
Much of this advanced medical treatment depends on better technology and equipment, operated by
more specialised clinicians. Medical advances mean that fewer hospital beds are needed. Most
routine surgery is now done in just one day (“day surgery”) and 80% of all patients have stays in
hospital of fewer than three days. Not surprisingly therefore, the number of hospital beds in NW
London has fallen by about 9% over the last five years. As medicine and surgery continue to become
more specialised, and new techniques allow people to go home even earlier, or avoid going to
hospital at all, the number of hospital beds will reduce even more.
The rise of the internet and mobile communications provide other ways for patients to access advice
about their health and communicate with health and social care professionals. This creates more
opportunities to support patients in their own homes and receive services, traditionally based in a
hospital, through more local facilities such as GP surgeries. This results in services being moved
closer to patients
‟ own homes.
However whilst there have been advances in the way we deliver healthcare has changed but more
needs to be done. The doctors, nurses, other clinicians, managers and staff of the NHS in NW
London have been working hard to constantly improve healthcare delivery across hospital, primary
care and in local communities. However, more can be done to meet the clinical challenges that the
NHS faces in NW London.
•
A greater focus needs to be placed on preventing people becoming ill. There is currently a
difference of up to 17 years in life expectancy in different wards in NW London. While this can
be improved through public health information and campaigns, more proactive primary care
and better integrated working can enable the whole system to respond collectively.
•
We need to do more to provide easy access to high quality GPs and their teams. To
reduce pressures on hospitals, and particularly A&E, access to GPs and primary care facilities
locally must be improved. Improved access will allow patients to receive a greater continuity of
care and reduce avoidable costs to the system.
•
More to support patients with long term conditions and to enable older people to live
more independently. If people with long-term conditions are not cared for well enough in the
community, they create a heavy burden for our hospitals. Similarly, effective local services can
help keep older people out of hospital and healthier for longer. Currently, too many older people
are admitted to hospital when, with appropriate out of hospital care, they could be treated in the
community and looked after in their own home.
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The financial Case for Change
Commissioners and providers face financial pressure
Although the Government’s pledge to protect health budgets has meant they fared well compared to
some other areas of public spending, expenditure will only be increasing very slightly in real terms in
the years up to 2015. Against this, the financial pressures caused by the increasing age of the
population, the increased burden of more ill health and the need to keep pace with new technology
would need growth each year unless we change the way services are delivered. As a result, the 2010
Spending Review committed the NHS to finding £20bn in productivity improvements by 2015 to
reinvest in services to meet increasing demand.
This means the NHS is required to deliver significant efficiency savings. NHS NW London is one of
the largest PCT Clusters in England. The totals spend in the NW London health economy is £3.7
billion. Without an underpinning strategy, NW London faces significant financial pressure unless we
respond to this agenda.
Savings identified by commissioners
Without action, the financial system is likely to move into deficit. In total, Commissioners plan gross
QIPP savings of £555 million, with re-investment of £190 million over the next five years.
Acute trust challenges in delivering QIPP
With the scale of the financial challenges, under the ‘do nothing’ scenario, most acute sites would
move into deficit under the base case with a zero net surplus. In the downside there would be a
deficit of £89 million across NW London and all bar one site would be in deficit. Without service
reconfiguration, Trust deficits are highly likely to worsen.
The bed capacity case
Alongside the impact of Commissioner out of hospital strategies, Trusts also need to deliver their
Cost Improvement Programmes (CIPs). A significant component of the CIPs is the need to reduce
the average length of stay. The effects of out of hospital changes and the length of stay reductions
mean that number of beds needed in the future will be less than the requirement now.
What would happen if we did nothing
The current configuration of services does not produce the best outcomes or quality of care for
patients. If nothing is done within the next few years, the following will start to happen within the NHS
in NW London:
•
Inequalities would continue and probably get worse: Currently people in some parts of NW
London die on average 17 years earlier than those in nearby areas. This is neither fair nor
reasonable and we need to try to reduce those differences
•
People would continue to die unnecessarily: A recent study showed patients admitted at
weekends and evenings in London hospitals, when fewer senior doctors are available, stand a
higher chance of dying than if they are admitted during the week. We need a system that allows
all of our hospitals to benefit from having senior clinicians on site at all times, (including
appropriate levels of consultant cover in key specialties such as emergency surgery and
obstetrics, as evidence is now directing)
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•
Our dependency on hospital services would continue when this is not the best use of
resources: Resources which could be better used to help people to stay well in the community.
The issue of the current poor state of many of our buildings would not be dealt with – two-thirds
of our hospital buildings need upgrading
•
Existing hospital trusts would be under severe financial pressure: The deeper ‘into the
red’ that trusts go, the more difficult it is to keep services running, to keep staff and maintain
morale, and to provide high quality patient care. Crucially, this would happen in a disorganised
way – meaning a worse effect on patients and staff
•
There would be problems with the NHS workforce: As it is, some services have already had
to be reduced because there are not enough clinicians to provide them safely. Recruiting and
keeping clinical staff in London is always a challenge and if we do not offer the best places to
work, and the best places to train, we will not attract the best staff. Equally, if there is not
enough senior staff, trainee doctors cannot be supervised and are withdrawn from the hospital.
All this means patients will not get the best care, and services will be reduced.
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