DQHH Report for Health Scrutiny Topic Group – January 2010.
Purpose
This report provides members with a resume of the key themes of Delivering quality healthcare for Hertfordshire; the progress that has been made to date and the focus for the local NHS over the next few years.
Background and Context
Delivering Quality Healthcare for Hertfordshire (DQHH) is a whole system’s approach to future service design and delivery. It was subject to public consultation in 2007. A key objective throughout is to move appropriate aspects of healthcare provision closer to home, away from acute hospitals to delivery in people’s homes or in more local facilities.
It confirmed the following:
o Consolidation of acute hospital services at the Lister Hospital Stevenage; Watford was already the agreed location for acute hospital services in West Hertfordshire.
o Planned surgery would take place at St Albans City Hospital for West Hertfordshire.
o Paediatric surgery and emergency surgery for West Hertfordshire would also move to Watford.
o In Welwyn Garden City and Hemel Hempstead the PCTs would lead the development of two Local General Hospitals.
o There would also be a network of 8 Urgent Care Centres including two pilot sites at Cheshunt and Hertford.
High level DQHH assumptions, as stated in the 2007 DQHH Consultation Business Case, proposed the following shifts in commissioning intentions in percentage terms:
Table 1 – DQHH Commissioning Changes based on percentage of spend from 2007/08 to 2012/13 (Pg 29 of DQHH consultation Business Case)
In essence, more funds would be directed towards primary care, community services and mental health services away from acute hospital care.
Our local approach has been reinforced by recent national initiatives such as the quality and productivity challenge set out by the Department of Health whereby local NHS organisations deliver quality services through a period of significant financial challenge.
The last two years have seen successful delivery of many of the changes outlined in DQHH, including investment in urgent care networks, local general hospitals and chronic disease pathways. Despite these efforts to date, acute hospital activity in Hertfordshire has increased over the last two years and, we have been unable to redirect resources to primary and community services as planned.
The priority is therefore to focus now with renewed vigour on the Care Closer to Home policy which is integral to DQHH. The commissioning intentions of the PCTs for 2010/11 set out our ambition to reach DQHH target levels by 2012/13: this will also be reflected in contracts with our providers.
Work is underway in the PCTs to look at the service redesign projects that will deliver this change and there is significant engagement with GPs, Professional Executive Committee and Practice –based Commissioning Groups regarding this work.
The Position in West Hertfordshire – where we are now
· Hemel Hempstead
Since the move of acute hospital services to Watford in March 2009, services have been consolidated on the Hemel site with the majority of services, including an intermediate care ward, now housed within the redeveloped Verulam Wing. Jubilee Wing houses the Urgent Care Centre and the GP- led Medical Centre; the latter opened in June 2009 to provide additional GP services for west Hertfordshire for registered and non-registered patients.
The Urgent Care Centre services are provided by a partnership of West Herts Hospitals Trust and Herts Urgent Care. The partnership was awarded a five year contract to manage and run the centre which is open 24/7, 365 days a year. Herts Urgent Care is a non profit making social enterprise run by local GPs and patient representatives.
The GP-led medical centre works alongside the new Urgent Care Centre and is open between 8am-8pm, 7 days a week, 365 days a year offering a combination of bookable and “walk-in” appointments. It is also run by Herts Urgent Care.
It is worth noting that Herts Urgent Care currently provides out-of-hours GP and emergency dental services to the whole of Hertfordshire.
The new Local General Hospital will be developed on the existing hospital site following a detailed site option appraisal process undertaken by NHS West Hertfordshire with local stakeholders and confirmed by the NHS West Hertfordshire Board (the PCT) in November 2009.
· Watford
Watford General Hospital is now the main acute hospital in west Hertfordshire. The specialist emergency department at Watford includes an expanded A&E Department, a new purpose built 120 bed Acute Admissions Unit, an expanded 19 bed Intensive Care Unit and a dedicated Children’s Emergency Department.
The Acute Admissions Unit (AAU) takes patients admitted as emergencies, either by emergency ambulance or by their GP. They are seen and assessed rapidly by an acute medicine consultant, who can call upon the advice of specialists in respiratory medicine, cardiology, neurology, gastroenterology and rheumatology, among others. This ensures the patients are cared for by the most appropriate specialty team.
The AAU also has a new pharmacy department with a modern robotic dispensary. This state-of-the-art robot provides a fast, accurate, fully automated dispensing process, ensuring a greater level of efficiency and reduced risk of errors, therefore increasing patient safety.
There are two new Cardiac Catheterisation Laboratories in the AAU offering quick and effective coronary angioplasty treatment for patients who have had a heart attack..
The Position in East & North Hertfordshire – where we are now
There is a planned phase approach to the consolidation of services in East & North Hertfordshire. Currently both hospitals have an A&E department; medical and surgical wards and maternity units. This is set to change over the next few years as Lister becomes the site for acute hospital care in east and north Herts and the QE11 is developed as a Local General Hospital.
· Lister redevelopment
Construction work on the surgicentre is well underway financed by Clinicenta, an independent sector partner which will also run the surgicentre on the Lister site. It will open for patients in Spring 2011.
The next phase of redevelopment is the consolidation of women’s and children’s services on the Lister site. Work has started on a new £16.4 million facility that will be completed in early 2012. The project comprises a two-storey expansion of the Lister’s current maternity and neonatal unit, which when completed will enable it to support over 5,500 births every year. There will be a co-located midwife led unit and a consultant led maternity suite to provide choice for women.
The inpatient birthing service at the QEII will transfer up to the new Lister based to bring specialist maternity and neonatal services onto a single site.
The QEII maternity service will continue to provide ante and post natal care for local women, as is the case today – this will not be changing and will form an integral part of the local primary care trust’s plans for the a new local general hospital.
The third phase of work is the development of a new multi storey car park to support the additional numbers of patients and visitors. Construction work on the £10 million project is expected to start in the spring this year, ready for opening 12 months later. The new multi-storey car park will be situated on the site of the current main public car park by the Lister’s main entrance.
The fourth and most significant phase is the consolidation of emergency care and theatre services onto the Lister site to complete the programme. The hospital trust is developing a business case supported by the PCT.
The plans include additional beds for coronary care, a medical high dependency unit.,additional theatre capacity, an extension to the Accident & Emergency Department plus diagnostic services. In addition, the business case will also propose that the current Lister tower block will be refurbished to provide additional critical care facilities and a second cardiac catheter laboratory.
QEII
Work on the Local General Hospital (LGH) is progressing in two ways. Firstly there is joint work with East & North Herts Trust on the site master plan as the Welwyn Hatfield Planning Dept need to understand how the site will work in the future as part of any planning application. This work is progressing and it is anticipated that an outline planning application will be submitted in Spring 2010.
The second area of work is to develop the requirements for the LGH in terms of the services and amount of activity that will take place there along with a brief for the architects and designers. This is being finalised and includes the ideas, hopes and issues that were raised at the stakeholder event in June 2009. A further update workshop with stakeholders is planned for March 2010.
The aim is to have an Outline Business Case ready to be presented to the PCT Board in May 2010, with the facility being operational in 2013/14.
Urgent Care Centre Programme
As mentioned earlier in this report, the first urgent care centre opened in Hemel Hempstead in October 2008.
In October 2009 two further Urgent Care Centres opened in Cheshunt and Hertford as pilots. They are open from 8am to 8pm, seven days a week (including bank holidays and are accessed on a “walk-in” basis. Ambulances can take patients to these UCCs if the paramedics assess that the centres are able to treat the patients.
The Cheshunt and Hertford UCCs are run by a partnership of East and North Hertfordshire NHS Trust and Assura Lea Valley LLP (a consortium of local GPs). They are being piloted for 12 months and an evaluation process, which also involves the local authorities in East Herts and Broxbourne, has been put in place.
The next stage of the urgent care centre roll out has been delayed. Procurement of the next stage – establishment of UCCs at St Albans and Bishop’s Stortford- was halted in October 2009 as it had not resulted in a financially sustainable tender. Discussions are now taking place with existing providers of the minor injury services in both areas with the aim of producing financially viable schemes for urgent care services. The intention is to open the new services in October 2010.
Intermediate Care
Hertfordshire’s vision for intermediate care services
Current intermediate care services cannot provide care in a sustainable way.
Changes are required to ensure services promote people’s independence in a changing demographic profile. This means that capacity and resources need to be used differently, in partnership with ACS and other providers, to reform the current system, bringing it into line with best practice and enabling more people to be cared for in their own homes
The NHS in Hertfordshire and HCC Adult Care Services (ACS) share a vision for Intermediate Care that supports faster recovery from illness, prevents unnecessary admission to acute hospitals, reduces the need for admission to care homes, with reduced intensive care packages and maximises the independence of older people in Hertfordshire. It needs to be accessible to everyone who needs it and provide care as close to home as possible.
The key to achieving this vision is to ensure that people are treated and cared for at the right time, in the right place, at the right cost and by the right professional.
This vision and a potential approach has been the subject of significant engagement and discussion with a number of stakeholders including a clinical reference group (whose membership includes practice based commissioners and acute trust representatives), PBC localities, Herts LINk, Stakeholder Forum and the PCT Professional Executive Committee. These discussions have been used to confirm whether the approach and vision is the right one and initial feedback has been positive.
To achieve the shared vision health and social care commissioners and providers will need to continue to work together in an integrated way, considering opportunities for joint commissioning and supporting the development of joint protocols and risk sharing agreements.. Currently the variation in costs across community hospitals is not sufficiently understood to clarify what the benchmark should be. This requires active exploration of the market and benchmarking costs against other PCTs’ costs to ensure services are purchased at the appropriate price and improve quality and improve outcomes.
The remodelling of the intermediate care system is a significant piece of work. Discussions between ACS and NHS Hertfordshire have taken place and it is planned to hold a workshop in March involving LINk representatives, the Intermediate Care Clinical Reference Group, ACS and NHS Hertfordshire to review progress and agree the next steps..
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