Collaboration between the three acute trusts - the third priority

The third priority is something to do with supporting the three acute hzospitals in the area to work together.

"Collaboration of the three footprint acute trusts to deliver equality and efficiency".

The CCGs description is:

"Consoloidation of backroom services to ensure high quality and optimise cost effectiveness".

What do I think this means?

To be honest I have no idea but I will try to guess.

Firstly what are the three acute trusts? I assume they mean the hospitals in Oxford , Reading and Buckinghamshire Healthcare (Wycombe & Stoke Mandeville Hospitals). At one time they were meant to be independent and in competition with each other. But things change and now it seems they have to work together to reduce costs.

What do they mean by backroom services? I assume that they mean the services that we, as patients, do not see but are vital for quality care. One service that could be ripe for consolidation (or centralisation or merger) is pathology. These staff in this service do all the diagnostic tests, the blood tests and tissue samples, that help Doctors identify what is wrong with us.

I used to work in pathology and I used to spend hours commuting on the train talking with a colleague about turning pathology into a large industrialised process.  He later went on to work on doing just that and it can work at large scale as long as there is a good courier system and good communications between clinicians and pathologists.

Other services such as personnel (AKA Human resources) and finance could also be consolidated.

What we really want though, is more information and more detail. There are stories that they want to reduce the number of nurses as well as 'backroom' staff.  But that seems crazy as we need more nurses not less for quality care. Of course the real question is can the three trusts work together for our benefit?

So what does this mean for patients. Hopefully it will mean more money for our care but who knows!

Impact of a shortage of GPs

In many parts of the country GP surgeries are having trouble recruiting Doctors and Practice Nurses. 

What impact is this having on patients and the care they receive?

My guess:

·        There will be a shortage of appointments, so patients will have to wait longer to see a GP.

·        Telephone lines will be even busier so it will be harder to contact the surgery.

·        Patients will be asked (forced) to see someone other than a GP.  This may be a Practice Nurse or a pharmacist.

·        More locum staff may be employed.

·        Practices may close completely.

·        Surgeries will close their lists to new patients.

·        Branch surgeries will be closed.

New patients will have to join another practice which may be some distance away from their home.

This will put pressure on these other practices as they get more patients joining the practice and the cycle continues.

Possible models of General Practice

Any number of organisations have looked at the possible models of General Practice in England (see below for some recent examples).  They have produced lots of glossy pages describing the issues and possible models.

So we thought we would produce a short list of the possible ways that a local community could get its GP service provided. In no particular order.

“The Status Quo”.  The partnership option.

Under the current circumstances, unless the government changes its attitude this is not a realistic option.

A Salaried service with GPs.

a)    Through Foundation Trust Hospital – Vertical integration.

b)    Through private companies i) groups of GPs, ii) multi-national companies iii) venture Funds etc.

A nurse led service

This would probably be with GPs as community specialists/consultants at a distance. (There would be no doctor as first point of contact, no legal right to a GP).

Walk In centres.

Patients would be triaged and referred onto the ‘appropriate’ Healthcare provider.

NHS111

All access to healthcare would be through NHS111 call centres

Federation

GP practices merge or federate to form a large organisation (Management & Admin merged to save money & probably staff used across all sites rather than based on a specific site).

Investment by Government

You never know it might happen. The government realises that the current system is the envy of the world and invests to support the development and innovation that has taken place over the last 30 years

I may look at the advantages and disadvantages of these options at a future date.

 Further reading

Nuffield Trust

http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/130718_securing_the_future_revised.pdf

RCGP

http://www.rcgp.org.uk/campaign-home/~/media/Files/Policy/A-Z-policy/The-2022-GP-A-Vision-for-General-Practice-in-the-Future-NHS.ashx

Kings Fund

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/commissioning-and-funding-general-practice-kingsfund-feb14.pdf

NHS England A call to action

http://www.england.nhs.uk/wp-content/uploads/2014/03/emerging-findings-rep.pdf

A&E issues in Buckinghamshire

There are a lot of unhappy people in the south of Buckinghamshire, especially in the High Wycombe area.  They want their A&E and other hospital services back! The sad truth is that this is unlikely to happen.

As I have written about previously (What is happening to my hospital)  the A&E service closed down in 2005 and first there was the Emergency Medical Centre then in 2012 there was the Minor injuries and Illness Unit (MIIU). This must have felt like a downgrading of services each time there was a change.

The authorities did not do a good job in explaining the reasons for these changes to the residents of High Wycombe and the surrounding area.

As part of their inquiry into the actions being taken as a result of the Keogh inquiry into Buckinghamshire Healthcare NHS Trust the county Council health and social care select committee is going to examine the provision of A & E services.

I am predicting that they will say something along these lines:

• Better facilities for A & E should be provided at Stoke Mandeville Hospital.
• More permanent  Consultants, junior doctors and nurses in A&E are needed at Stoke Mandeville Hospital.
• Better parking is needed  at Stoke Mandeville Hospital.
• Better transport links (roads and public transport) between High Wycombe and Aylesbury are needed.
• An effective and regular publicity campaign about the appropriate service to use (A&E, MIIU, Pharmacies, GP surgeries etc.) is needed.

They may use a few more words though.

See press articles

http://www.bucksfreepress.co.uk/news/healthnews/10718683.Campaigner_calls_hospital_crash_response__a_joke_/

See Steve Baker MP for High Wycombe Blog

http://www.stevebaker.info/2013/10/farce-at-wycombe-hospital/

My questions at the AGM (Buckinghamshire Healthcare NHS Trust)

In the previous blog I gave my own highlights of the Buckinghamshire Healthcare NHS Trust AGM.

After the Chief Executive gave her presentation and the finance director gave his summary of the financial situation we heard from the leaders of the emergency surgery teams. They described how they had changed the service, what is called reconfiguration, and how the new service was producing better outcomes for patients & reducing mortality rates.  Good news.

At the end of the event there was time set aside for the public to ask questions.  I have no idea how many members of the public were present but I was virtually the only person who asked questions. 

Why is it that people don’t ask questions in formal board meetings?  I reckon most people know the answer to that one.

I asked a couple of questions:

The first was about the campaign to restore an A&E department to the High Wycombe Hospital site. A petition with 16,000 signatures has been organised.

There are 16,000 people in the south of the county who believe that there should be an A & E on the Wycombe Hospital site.

Can I ask that the Communications teams from the Clinical Commissioning Groups and the trust remind us, on a regular basis, about the good clinical, organisational and financial reasons why, in the present circumstances, there can only be one A & E in the county?

This is an on-going issue for those who live in High Wycombe.  The A&E department was closed in 2005 after a public consultation and replace with a minor injuries type of service.

As we know from other examples of such closures the local population is incredibly loyal to their local hospital. MPs too! So the story here is how to sell the difficult and complex reasons, hopefully evidence based, for such closures.

In my opinion the only way to tell the story is to keep it simple and be persistent.

However the audience was asked what else could be done to explain the reasons why there are only resources for one A&E department in the hospital.

My suggestion is that the leaders of the campaign should meet with senior clinicians and managers (and the commissioners) to have an informal, facilitated discussion and look at the evidence. 

As for how to improve the conversation between the hospital executives and the patients is something to explore in another blog.

*****************

The second question I asked was about the way they manage complaints.

Can I ask that the board measures its performance on managing complaints by using the following as outcome measures?

a)    Is the complainant satisfied at the end of the process

b)     has the trust learnt from the complaints  

c)    has the trust acted on the learning.

Normally the first thing that the board reports is that they replied to people within the required time. This is important of course, but I reckon that most people would say the best test of a good complaints service is: was I happy with the result?

  I hope that the trust may consider that a different approach will improve the way people think about the way complaints are managed.

They expressed some interest in this approach and said that they are trying to do something like this.  They have been contacting people by telephone after the complaint has been closed, especially complex complaints. But they have not been recording this activity. It sounds as if they are looking to improve the experience of complaining.

They did say that they get many more accolades than complaints. This is good to hear. 

Measuring improvement in the quality of care after reconfiguration of NHS services

I asked a question at a public meeting of our local Health Overview and Scrutiny Committee. They have a slot for questions from the public.  I asked if the PCT and hospital would provide a baseline from which to measure the improvement in care promised as a result of the centralising of services on one hospital site.   

I have posted a couple of stories about the difficulty I have had in getting an answer to this relatively simple but important question:  "Like getting blood from a stone" & "What is a 'benefits realisation'?".  I finally arranged a meeting with the hospital managers who are delivering the data. It is really important to talk to the right people.

They were very helpful and, despite being busy implementing the changes, they spared an hour of their time to talk with me about how they are measuring the quality of care.  They reassured me that they have plenty of quantitative data, such as re-admission rates, length of stay, avoidable admissions and mortality rates from before the changes and they will be collecting similar data from the newly reconfigured services.   Now that is good news.

They will not be publishing the data until they have the first set of new data so that there can be a comparison made between the old and the new.   This data will be collected routinely and published regularly. More good news.

We had a discussion about how to present the results in a form that the patients and public can understand.  Not an easy problem to solve. 

We also talked about using qualitative data from the patient experience to complement the hard numbers.  Now I think that the patient experience is a really good test of quality.  The government thinks so too because the 'Friends and Family' test depends on patients feeling they had a 'good' experience in a hospital.  I am not sure that any time spent in hospital can be considered good though.  This sort of data is more difficult to get and use but we agreed that it is important as the patient can have a different perspective compared to a healthcare professional or a manager. 

The hospital has been collecting this sort of information for some years and they said that they will be using it in the baseline measure as well as in the future. 

So my question has been answered at last and I feel reasonably certain that they have the data, both quantitative and qualitative, to measure the quality of the services in some way. 

What will be more interesting is what will the patients and public make of it?  Do they care about tables and charts showing that the number of people re-admitted within 28 days has been reduced by 5%?  Will they care that 95% of patients in a recent survey said that they had a satisfactory experience in the hospital?  Will they use this data to compare the quality of different service providers? Will quality information from other providers be comparable? 

Only time will tell.

What is a 'Benefits Realisation'?

In the summer I asked some questions at our local council Health Overview and Scrutiny Committee about how would the public know that the planned reconfiguration of services at our two local hospitals would benefit patients and what were the baseline measures for the specific services being changed.

The answer I got from the PCT was "in relation to the Better Healthcare in Buckinghamshire programme, a benefits realisation performance dashboard was being developed".

At the time this went straight over my head and all I could think about was that they had not answered my question on baseline measures.  I have described my effort to get the information in a previous blog (Like getting blood from a stone).

Recently there was a twitter discussion (#NHSchange) on measurement for improvement and someone used the phrase 'benefits realisation' in a tweet.  I complained about the use of jargon but was challenged to find some alternative wording.

I had to think a bit but did come up with some suggestions for a patient friendly version.

"Is my experience as a patient better now than it was before the change/redesign/reconfiguration?"

"Is my outcome (better health, less pain, ability to work, feel better) improved as a result of the change in service provision?"

I also did a bit of research and even went back to a PCT paper on benefits realisation.  In the document it said "Better Healthcare in Buckinghamshire will begin the development of a business case from which the benefits realisation plan can be further developed". However I could find no trace of such a plan in the public domain.

The paper also said that it was important to set current baseline against which to measure benefits.  This is, of course, what I was asking about in my question to the scrutiny committee. But it did not appear to have been done.  Luckily I have a meeting with the Trust to discuss this issue in a few days and I can use this information in my discussions with them.  I will report on what happens at the meeting.

As part of my research I googled 'benefits realisation' and first up was the NHS Institute for Innovation and Improvement's (NHSIII) website where they have a paper on the topic. It is interesting and worth a read. http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/benefits_realisation.html

In their view a benefits realisation is

"a tool to make sure you actually get the intended benefits originally planned for your project". 

I like that! Clear and concise.

Further on it says

"A benefits realisation should be a fundamental part of any improvement project running from the projects beginning to the end and beyond".

Now that confirms my view that you need to know the baseline so you can measure the effects of the change you are implementing. It seems so obvious.

*****************

So if you are running an improvement programme and you want to know if it has worked I suggest you read the NHSIII paper and make sure you have a benefits realisation framework established at the beginning of the project.

What is happening to my hospital?

I guess lots of people around the UK are asking this question?

All around the country NHS managers and doctors are proposing to change the way services are provided in our local District General Hospitals. These much loved hospitals, with a loyal following of local people, are having the services they provide reduced or moved to another hospital.  Beds are being cut, wards being closed.

What is happening and why?

Reduction in beds and ward closures.

It is claimed modern medicine is done in different ways now compared to even 20 years ago and so there is no need for so many hospital beds. The time spent in hospital is shorter, more surgery is done as day cases and more patients are managed at home or in the community.  This means that the managers believe that hospitals mean fewer beds.

Closure of A& E Departments.

The experts from the medical  Royal Colleges tell us that A&E departments need more specialist doctors and nurses to provide a safe service 24/7.  Hospitals also have to meet the 4 hr target for waiting in A&E. So rather than employ more staff (There is a national shortage of A&E consultants anyway) the managers are merging A & E departments and closing some down.  This is happening all around the country.

Centralising services (reconfiguration and redesign).

The Royal Colleges tell us that to ensure high quality care is provided the doctors and nurses have to see enough patients to keep up their levels of skill and experience.  In many cases our local hospitals do not have enough patients so the departments are merged and moved to another hospital, perhaps in the next town. This process is called service reconfiguration or service redesign and is taking place in most hospitals across the country.

Hospital mergers.

An extreme situation is the closure of a whole hospital and merging it with a bigger hospital. This is happening in big cities.

What is happening in Buckinghamshire?

There are two district general hospital, managed as a single hospital, in Buckinghamshire, in the two big population centres, High Wycombe and Aylesbury.  Before they were merged the two hospital provided a full NHS service for inpatients and outpatients.  Since the merger there have been several proposals for change with all the associated consultations with the public. A number of services have already been moved to one site (stroke and Cardiology).  The performance of the stroke service for acute patients has improved as a result of the creation of a Hyper Acute Stroke Unit at Wycombe.

Now the mangers are implementing the next round of changes following a public consultation called 'Better Healthcare in Buckinghamshire'. http://www.buckspct.nhs.uk/bhib/

The following changes are now being implemented:
A&E consultant teams are being centralised at Stoke Mandeville Hospital (SMH), Aylesbury.
Reduce the Emergency Medical Centre at High Wycombe to a Minor Injuries and Illness Unit (The A&E was closed earlier).
Centralise specialist inpatient care for emergency medicine , respiratory, gastroenterology, medicine for older people and diabetes at SMH.
Centralise breast cancer services at Wycombe.
Transfer complex vascular surgery to Oxford but retain routine vascular surgery.

There are other service improvements planned such as a day assessment unit for elderly patients, a step down ward and admission avoidance services.

How do people feel about these changes?

Local residents in High Wycombe are concerned that they will no longer have an A&E department even though they are next to the M40 and the town has a population af about 100,000 people.
They feel that the hospital is being run down as services are centralised at Stoke Mandeville Hospital in Aylesbury (15 miles away along country roads). Following the latest consultation the PCT and the Hospital, together with the county Council, are looking at the transport infrastructure in the county, especially for those who live in the outlying villages. It seems amazing that this was done at the time the proposal was developed!  The NHS considered that transport was the responsibility of the Council and so did not address the issue at the time. The patients see things differently.

Local campaigner felt the changes were to save money and to reduce the size of the hospital. They see the changes as the thin end of the wedge leading to eventual closure.The PCT and hospital managers insisted that the changes were all about improving clinical quality.  The changes had nothing to do with reducing expenditure.

People do not believe them.

I have asked for information on how we will know that the quality of care has improved (see my earlier blog "Getting blood from a stone".  They have a 'Benefits Realisation Plan' but I think the public need something they can understand. I have a meeting soon with the hospital and I will update this blog after the meeting. 

The question that needs to be asked about all these proposals is:

Do people want a gold standard service and have to travel some distance to get it or do they want local access to a hospital and have care at a reduced quality?

Like getting blood from a stone

It started like this.....

Our local Hospital Trust and the Primary Care Trust (PCT) decided that they needed to reconfigure services across two of its three sites. I guess that there are many reasons why they should choose to consider such a redesign. There is the European working hours directive for doctors, medical training requirements &  Royal College recommendations etc etc., all of which suggest that some services needed to be centralised on one site and some on the  other site.

A few years ago they held a public consultation on the general principles of such a change and it passed without too much fuss. Obviously they then went away and developed proposals on how the reconfiguration might look, A number of options were identified, including leaving services as they were. This option appraisal then went out for another extensive round of public consultation.

The consultation agreed with the preferred option (surprise!) but once the implications of the proposals were known and discussed in the press the public began to express their concerns about the effects of the changes at a local level. 

These concerns were a) that it seemed that one of the two hospitals seemed to be reduced in size and in services, b) its A&E becoming an Emergency Medical Centre, and c) the issue of poor transport links between the two hospitals, especially for those living in the villages outside the major towns.

There was an extensive campaign by the local press and a 'Save our Hospital' group held meetings.  Managers from the hospital Trust and the PCT attended these meetings, made statements to the press and a useful debate took place. One of the interesting statements made was that the changes were designed to improve the quality of care and had nothing to do with money.  "Its all about quality".

This got me thinking about how we , as members of the public and patients, would know that the changes have achieved their desired outcome, that of improving the quality of care.  As a scientist and part time 'change manager' I realised that we needed a baseline measurement of the current quality of care provided by the existing services.  So I asked the question.

The County Council Health Overview and Scrutiny Committee was being updated on the reconfiguration and so I asked a question about getting quality information into the public domain.

The important part of the question was:

"Given that the aims of the changes.....are all about improving the quality of care ...can the Hospital and PCT provide the current level of quality of those services in a form that the public can understand."

Their answer in full (names and details removed to protect the innocent) (from the PCT director of communication and engagement) was:

"Quality reports are routinely considered at meetings in public of the PCT cluster Board. These look at issues such as waiting times, levels of hospital acquired infections and delayed transfers of care. In relation to the changes proposed by the programme, a 'benefits realisation' performance dashboard is being developed. This will contain a number of indicators which will be monitored to ensure that any changes are producing a better experience and better outcomes for patients.  This will look at factors such as patient satisfaction, mortality rates, length of stay and admission and readmission rates of these services which have been changed."

Now I know I am just a member of the public but I did spend two years teaching science to GCSE students and I reckon that comes under the category of 'this student did not answer the question'.

Now in my role of 'a stone in the shoe' I had a email conversation with the Trust representative ('the messenger') which resulted in no improvement and so I was allowed to re-ask the question at the next Overview and Scrutiny meeting .

This is the next answer, given by a senior clinician from one of the two embryonic local Clinical Commissioning Groups:

"At the moment a large amount of data is collected the Trust.  This includes data on length of stay, readmission rates and mortality rates. However the way in which this data is currently analysed and reported reflects the current arrangement of services not the proposed new reconfiguration. The Hospital Trust is currently undertaking an exercise to analyse the data to reflect the changes and to determine benchmarks from which outcomes can be monitored. Once this is completed the key indicators will be published and monitored in the public domain".

Once again it seems to me that they have avoided answering the question. In fact they seem to have missed the point about establishing the quality of the current services, entirely. Yet at the same time they say that the way the data is analysed at the moment does reflect the current services!  If this is so they should be able to give some indication of the quality of the current services.

Each time I go over the answers I see more confusion and lack of information.

It seems to me common sense that the baseline for measuring quality improvements should be taken before the changes are implemented and are an essential piece of information that any organisation should use when managing change. 

The more I look at what has happened over the last few months the more concerned I am about the ability of the local health services to understand the quality of service that it provides for the local population. They do not seem to understand the process for monitoring the change process either!

We are being told to choose the health care provider that gives the best quality care but if they cannot give us the information on quality how can we choose?

Or is it that they do not want to tell the public what is happening?