Aspects of Acute Services Redesign – Key Messages from the literature
1Summary of Key Messages from the Literature
1.1Drivers for change
- The issue of Acute Service Redesign is pertinent to health economies across the UK, and many are reviewing their acute services with a view to improving sustainability
- There are a number of common drivers for acute service redesign; changing disease patterns – increasing numbers with chronic conditions, rising emergency admissions, outdated current configurations, implementation of European Working Time Directive and consideration of the evidence base in relation to volume and outcomes.
1.2General points on service redesign
- There should be a focus on locally provided core services, with not all services available on all sites. It is anticipated that this is achieved through some of the following:
Strengthening chronic disease management programmes in the community, primary care, intermediate setting
Managed Clinical Networks – joint working between hospitals, well developed transfer arrangements
Innovative approach to workforce redesign and extension of staff roles
Separation of elective and emergency cases
Development of ICT – use of telemedicine, electronic patient record and digital imaging transfer
- There is a decline in access to services with increasing distance from medical care. Rural patients in the UK are more likely to have advanced diabetic retinopathy, higher mortality from asthma, higher death rates from trauma and lower rates of access for angiography and revascularisation
- NHS Scotland proposes a model based on networks of rural community hospitals and Rural General Hospitals.
1.3Emergency/Acute Care
- Innovative approaches to service design in relation to Emergency Care include; use of ambulatory care models, Emergency Care Networks, ‘See and Treat’ model and the use of medical assessment units alongside emergency departments
- Providing care through Clinical Networks as described in much of the literature will inevitably require the transfer of acutely ill patients at times. This should always be done following the Intensive Care Society Guidelines for the Transportation of the Critically Ill Adult
- Workforce redesign and the extension of staff roles will be an essential part of any acute service redesign.
- Information and Communication Technology is a key aspect of service redesign. Telemedicine, the Electronic Patient Record and the digital transfer of images will be a vital part of working in an integrated way across community, intermediate and acute care, and in working as part of Clinical Networks
- Access to services, particularly in relation to public transport and NHS transport systems is key when any service redesign is considered
1.4Management of chronic/long term conditions
- To date there has been limited systematic use by the NHS in Wales of GP based information on chronic diseases for planning purposes. Data collection as part of the Quality and Outcomes Framework could improve this.
- There is a move towards a more generic approach to management of long term conditions i.e. basic principles of management are the same regardless of the specific condition
- Key elements of an effective chronic disease management programme include; broad managed care programmes, targeting high risk people, sharing skills and knowledge, patient involvement in decision making, self management education, self monitoring, telemedicine and use of disease registers.
- Effective programmes can improve clinical outcomes and quality of care for people with chronic diseases, and ensure they are managed predominantly in the community setting, therefore reducing hospital admissions and attendances.
2Background
The purpose of this document is to support the work currently being undertaken by the Mid and West Wales Acute Services Reconfiguration Project Team and the NPHS Designed for Life project team, by reviewing the current literature relating to aspects of acute service redesign and pulling out the key messages. Alongside this, aspects relating to the management of long-term conditions will also be considered.
The reasons for re assessing the way health services are designed in Mid and West Wales are clearly set out in both the Designed for life Strategy1 and the Case for Change2 document. Designed for Life outlines a 10 year strategy to deliver a world class health service in Wales by 2015, and the Case for Change highlights the point that in order to achieve this for the people of Mid and West Wales, the current uncertain and uneven delivery of care needs to change towards a system that ‘delivers high quality services as close to people’s homes as possible’ balancing this with the safety and quality of care.
3Methodology
The NPHS Library and Knowledge Management Service supported this piece of work by undertaking a literature search. Keywords used were; medical assessment units, patient admission, hospital admission, medical decision making, hospital configuration, hospital reconfiguration, medical admission units, admission units, review, acute care. In addition to this, relevant and reputable key websites were searched for reports and documents (See appendix 1 for list of websites searched). Some snowballing from reference lists of key documents was also carried out. Colleagues known to be undertaking relevant work were contacted (e.g. for long term conditions).
The timeframe for the production of this document was extremely tight and the subject matter extremely broad, it was therefore impossible to carry out a rigorous systematic review or to review all the literature in relation to the key areas. Key reports e.g. those by Department of Health, Welsh Assembly Government, Royal College Reports, NHS Scotland etc, and evidence reviews were prioritised. It is the purpose of this report to highlight the key messages and provide a platform for discussion and further review of specific areas if necessary.
4Drivers for Acute Service Redesign
The Wanless report confirmed that the current health and social services in Wales are not sustainable and have to change3. Designed for Life warns that if change does not happen we risk spreading resources too thinly, misusing and diluting clinical expertise, being unable to recruit skilled professionals, services being overwhelmed by demand and specialist services being too fragmented2. What became very clear early on in this piece of work is that these problems are not unique to Wales and that health economies in England, Scotland and Northern Ireland are facing similar challenges. Many areas are undertaking reviews of their health services with a view to creating more sustainable services. Reviewing the work being undertaken in other areas across the UK revealed common driving factors for the redesign of acute services, and these are discussed below.
4.1Changing disease patterns
Much of the literature emphasised the ageing nature of our society and the likelihood of increasing life expectancies in the next 20-30 years4,5,13,14. With this demographic pattern, the number of people with chronic conditions is also likely to increase. One third of adults in Wales currently has at least one chronic condition (800 000 people) and it is estimated that this will rise by 12% by 2014, with a 20% rise in those aged over 6511
4.2Rising Emergency Admissions
There has been a sharp rise in emergency admissions across the whole of the UK in recent years7,9,10,11placing increasing pressure on the acute sector, a rise of 22% in Wales in a decade11. Two thirds of emergency medical admissions in Wales are as a result of a worsening chronic condition or for patients who have an existing chronic condition. There is increasing evidence that managing patients with chronic conditions effectively in primary, community and intermediate care can prevent admissions and lead to higher levels of patient satisfaction11,12
4.3Outdated current configurations
It is now recognised that many of the current configurations of hospital services are not sustainable2,4,5,6,7, and are often outdated4. In order to deal with changes in the workforce and rising emergency admissions against the backdrop of changing disease patterns, there needs to be a move towards proactive, local, integrated care for chronic conditions with specialised, episodic care for acute conditions when necessary5.
4.4European Working Time Directive
In the literature, the European Working Time Directive was repeatedly cited as a powerful driving force in looking at the way services are provided1,2,4,5,6,7,8,9. This directive, due to be implemented in 2009, affects the number of hours junior doctors can work (48 hour week). If current working patterns stay the same a big increase in the number of doctors would be needed to run a 24 hr service. This would provide particular problems for smaller hospitals with limited staff4,5,8. In relation to the E.W.T.D, Sir John Temple in his Securing Future Practice report notes40;
‘..Limitations on medical staff time is a powerful lever for service redesign…clinical situations for which triage and transfer arrangements are appropriate must be made on the basis of patient safety, balancing issues of speed of access to specialised medical services against what it will be possible to provide and sustain locally. We recommend this is addressed urgently and realistically, in many situations the status quo cannot survive’..40
Some innovative solutions to this problem are being considered, one of which is the Hospital at Night project. In this model multidisciplinary teams work in shifts overnight to manage the clinical needs of patients at night. Initial evaluations of this project are encouraging27.
4.5Relationship between volume and outcomes
There is now good evidence that centralising some highly specialised services into fewer sites provides a safer service with better outcomes for patients4,5,15,16. Some examples of these services include paediatric cardiac surgery, vascular surgery, cardio thoracic surgery and some cancer surgery4,5,15. This has been a clear and straightforward driver to redesign some specialist services to ensure the best outcomes for patients. There is good evidence however to show that routine, common procedures and conditions can be managed in smaller more local hospitals4,5,15,16. The evidence appears to show that for common procedures clinicians need to ‘undertake a minimum number to maintain their skills but thereafter there is no great clinical benefit in specialisation or need for it’5.
5Key Themes arising from the literature on Acute Service Redesign
The next part of this report will look in detail at the key features of service redesign that have been considered and implemented across the UK
5.1Keeping the NHS Local
‘Keeping the NHS local’ (England)sets a clear direction of travel for the NHS when considering expansion and service redesign. It focuses on smaller hospitals and has 3 core principles:
- Developing options for change with people not for them
- Focus on redesign not relocate
- Taking a whole systems view
The document is clear that the majority of health services should be provided locally and with imaginative approaches to service redesign, smaller hospitals can be sustainable. It describes the problems that have occurred with reconfigurations in the past when, faced with competing pressures two smaller hospitals have merged. The report states that there is evidence that this approach does not necessarily deliver the expected benefits. ‘The link between volume and outcome for many surgical procedures is often overestimated, the financial benefits do not always materialise and access is reduced with a greater burden on older and poorer people’4. It sees an emphasis on core services and joint working between organisations as the key to maintaining local access. The report sets out the principles, which all health communities are expected to apply when developing service models and the Independent Reconfiguration Panel will use it whenever they form a judgement on a proposed service reconfiguration.
In relation to local access to services, a consultation exercise conducted as part of the National Beds Inquiry found support from the respondents (487) for the provision of care close to home. Respondents had the choice of three models; 1. Maintain current direction, 2. Acute bed focused service 3. Care closer to home. There was almost universal support for the care closer to home model that advocated a major expansion of community health and social care, with acute services focused on rapid assessment42
The recommendations in relation to service redesign set out in ‘Keeping the NHS Local’ are supported by two additional configuring hospitals evidence files, describing the evidence base and examples of service models16,17. The document describes 4 different models of service redesign aimed at smaller hospitals with a view to improving sustainability (See Appendix 2). The models are being piloted at different sites across England, there does not appear to be any evaluation reports from these pilots available as yet. Some key elements of some of the models are as follows:
- Integration of primary, secondary and intermediate services
- Senior clinicians at front end of emergency care
- Rapid diagnostics
- Extended working day. Strong day/night differentiation
- Nursing practitioners as first line cover
- Local acute assessment separate from treatment services, with telemedicine links to local acute hospital for joint assessment and transport links to larger centre
- Acute medical admission supported by critical care, with no emergency surgical admissions – surgery working as a network with access to surgical opinion on call
- Services working as part of clinical networks with well developed transfer arrangements in place
- Ambulatory care providing services for diagnosis, outpatients, elective surgery, urgent treatment other than for seriously ill patients, low dependency care, chronic disease management and intermediate care.
‘Keeping the NHS Local’ emphasises the need for local access to core services, with an acceptance that not every service can be provided on every site. The document proposes integrating services, taking a whole systems approach, working within clinical networks, using innovative approaches to the workforce and making full use of telemedicine. It suggests that using these approaches can provide sustainable solutions for smaller hospitals and can ensure care is delivered as locally as possible where appropriate.
5.2The Kerr Report
‘Building a Health Service fit for the Future’ is the new National Framework for Service Change in Scotland. The National Framework Advisory group was chaired by Professor David Kerr, MSP. The report sets out a 20 year plan for NHS Scotland and was developed with public engagement and from a series of reports from multidisciplinary action teams who looked into specific issues such as elective care18, unscheduled care9, remote and rural access19, volume and outcomes15 and long term conditions20.
The report describes similar drivers for service change as those described above and is consistent with ‘Keeping the NHS Local’ in its vision to provide the majority of care locally. The proposals of the framework include the following
- Systematic approach to management of long term conditions – management at home or in community where possible
- Multidisciplinary teams in community casualty departments providing vast majority of unscheduled care – networked by telemedicine to emergency units
- Separating planned care from urgent cases, treating day surgery as the norm, enabling better community based access to diagnostics
- Concentrate specialised or complex care on fewer sites to secure clinical benefit or manage clinical risk
- Develop networks of rural hospitals and establish ClinicalSchool for Rural Health Care
The Framework also describes a model for the management on unscheduled care based on four levels (See appendix 3)
5.3Health services for rural and remote communities
The evidence base in relation to rural and remote communities shows that there is a decline in access to services associated with increasing distance from medical care, and poorer health outcomes of remote rural residents19,21,22. Rural patients in the UK have been found to be more likely to have advanced diabetic retinopathy, higher mortality from asthma, higher death rates from trauma and lower rates of access for coronary angiography and revascularisation22. Mungall notes that the increasing trend towards centralisation of services disproportionately impacts on those living in rural and remote areas, in particular those with low incomes, poor access to transport, the elderly and disabled. Mungall goes on to cite a study of cancer patients in remote Scotland and their experience of accessing specialist care. The patients spent 22 days (13% of their remaining life) travelling to or in hospitals. The effect of centralisation can therefore be that the costs saved by the health service are passed to the patients22.
Mungall supports the models set out in ‘Keeping the NHS Local’ as a way ofcontinuing to provide high quality services to rural communities, by such initiatives as linking community emergency units to larger central emergency units by videoconference. He cites team working, networks, IT, improving rural transport, outreach clinics, potential rural career pathways and equitable funding as other key areas that are important to consider.
The National Service Framework for Service Change in Scotland Rural Access Action Team produced a report on the future of providing health care to rural and remote communities in Scotland. The report describes a model where Primary Care Practitioners will be skilled up to provide screening, assessment, diagnostic and treatment services in the primary, intermediate or community hospital setting. The models sees community hospitals as being the first port of call for the majority of care in the rural setting, providing A&E services staffed by Emergency Nurse Practitioners supported by local GP’s. Initial care for MI’s, COPD/asthma exacerbations and strokes could be provided in the community hospital with patients being transferred as necessary. The report also states that community hospitals could provide stabilisation prior to transfer for major trauma. Other important services that the model proposes could be provided from the community hospital include:
- Access to diagnostics
- Midwife led maternity unit
- Palliative care
- Out patients
- Specialist clinics
- Telemedicine
- Rehabilitation/Convalescence
- Alcohol Detoxification
In this model, the community hospitals would be linked to Rural General Hospitals through Managed Clinical Networks, ensuring safe and effective pathways of care. Rural General Hospitals would provide: