The objective of the Clinical Services
Strategy is ‘the right care, in the right
place, at the right time’. To
achieve this our aim is to create a network of Local
Care Hospitals that would undertake high-volume scheduled services closer to
home: outpatients, diagnostics and day care surgery. The network will be supported by a
We expect to be able to be more specific about the services proposed for the Critical Care Centre at the panel meeting in June.
Our expectation is for a network of Local Care Hospitals. These will be sited in population clusters. We intend to state the number of Local Care Hospitals and the population clusters or areas in which they will be located. Formal consultation in July-October will invite people to comment on whether or not that network could be improved upon.
The
This document
proposes ten criteria against which the network of
An explanation, some comments and also potential questions are listed for each one of the 10.
This document is an internal NHS working paper, which is being placed in the public domain for transparency of decision making. Although an internal NHS paper, we would be happy to receive comments up until the end of April.
In order to evaluate the sites against these criteria, we are already collecting data for the appraisal process in June. Should new criteria be suggested (or modification of these) we would need to know in time to mount the necessary data collection. The end of April would be preferable to allow us to have the extra data ready for June.
The criteria can be grouped under five broad questions:-
Will it achieve what we want to?
1. Fit with model of care
2. Service capacity and national policies
3. Quality
What is the right location?
4. Accessibility for patients and visitors
5. Staff recruitment and selection
Can it be achieved?
6. Technical deliverability
7. Strategic Fit
8. Partnership working
9. Impact on the community
10. Future flexibility
1.0 Fit with model of care
1.1 Definition
How well it contributes to the model of care described in the clinical service strategy and strategic outline case.
1.2 Some context and explanation
The model of care proposes a network of local care hospitals working to deliver as much care locally to patients as possible supported by a single critical care hospital treating only the sickest or more complex cases.
1.3 How this will be evaluated
Local Care Hospitals – achieving a network of local care hospitals is key. We will propose as wide as possible, to serve population clusters. The major constraint will be critical mass: for various hospital functions there is a minimum size and volume which is efficient and effective.
The appraisal panel will test the proposal by questioning the expert evidence to see whether a better proposal could have been made.
Critical Care Hospital – the key issue is how will the Critical Care Hospital support the Local Care Hospitals in their work and this seems more likely to come down to the way staff work, rather than location.
However, each site option will be rated by the panel as to how well it will contribute to the model of care.
1.4 Other commitments
There have been other formal consultations and commitments on the public record – for assistance around the transfer of Queen Mary’s Hospital for Children, and around Renal.
Each option for the Critical Care Hospital will need to be evaluated as to how well it meets these commitments.
2.0 Service capacity and national policies
2.1 Definition
The ability of any site to enable the service model to deliver existing NHS Plan targets and to have the ability to deliver new policy initiatives.
2.2 This is a standard requirement in OBCs from the DoH. Each site option would be based on the same assumption about targets to be met and medical practice (length of stay, bed occupancy etc), so it is unlikely that any option would be rated differently. [However, the criterion ‘flexibility/robustness’ is important in this respect. Should the assumptions prove wrong, or more targets get added between now and 2010, then sites which offer the ability to respond are to be preferred to those which are more constrained.]
2.3 How will this be evaluated?
Local Care Hospitals
We will propose a network of Local Care Hospitals to serve population clusters. That is in itself in accord with the NHS policy ‘Keeping it Local’; and also is more likely to assist in responding to the policy of Patient Choice. The question for the panel is whether any other network than that proposed would improve the ability to deliver capacity and policy.
Critical Care Hospital
Each site would be built within the capacity necessary for the caselaod estimated for 2010.
2.4 Comment
This criterion is here because it is standard in an OBC – and it was an important part of the justification for creating a local care/critical care network. But it is unlikely to differentiate between the actual sites for the hospitals in that network.
3.0 Quality
3.1 Definition
How well each option supports the delivery of good quality, modern services.
3.2 Some context and explanation
The site must enable best practice to be implemented so that clinical quality is sustained over time. The site must also support the flexibility to develop clinical effectiveness and accommodate new services.
In addition, the site needs to enable high quality teaching, training and research to take place, whilst maintaining privacy and dignity of individuals.
3.3 How will this be evaluated?
Local Care Hospitals
We will propose a network of Local Care Hospitals situated to serve population clusters. For the most part, quality of care is independent of location and comes from the interaction of staff within the buildings. Perhaps the most important thing for the panel to concentrate on is the extent of decentralisation achieved – patient experience will be maximised if a good range of diagnostics are on site so visits to other places are unnecessary.
Critical Care Hospital
Again, it is mainly the interaction between staff within buildings that promote quality; however, there is some evidence that inpatients benefit from contact with the natural environment, so sites which offer views of trees, grass and good natural light are to be preferred. In addition, sites which enhance the ability of staff to learn and develop are better than those which do not.
3.4 Comment
Our intention is to compare like-with-like; costing all sites on the basis of demolition/clearance followed by new build; then showing savings wherever a refurbishment can be used to avoid new build. Nevertheless, however good the refurbishment, the relationship between departments which have emerged over time may not be as good as achieved when compared with a development planned as a whole new building.
4.0 Accessibility
4.1 Definition
How easy it is for patients (and their visitors) who need the facilities to get to them.
4.2 Context and explanation
Many services will become more accessible since they will be decentralised to Local Care Hospitals. Some will become less accessible if they are located at a single Critical Care Hospital. Public feedback suggest this is a significant issue. Our objective would be, all other things being equal, to minimise travel times for patients and visitors. (And also staff, but this is to be evaluated against the criteria of recruitment and retention).
4.3 How this will be evaluated
Local Care Hospitals
A network will be proposed, as wide as possible to support population clusters. At the evaluation stage the panel will explore whether these are the right clusters.
During the consultation period we expect to explore how to realise the best location within any given population cluster.
Critical Care Hospital
For each three options we will provide estimates of travel times by car and by public transport, from a number of start points (probably electoral wards) over a number of different times at weekdays, evenings and weekends. We will also ask the two Ambulance Services to estimate ambulance journey times.
4.4 Questions
Are there some groups of patients whose travel time is more important than others
- for instance Maternity cases, or serious A&E cases?
- for instance Patients as opposed to visitors
- for instance Those over 65 as opposed to under
- for instance Those without access to a car
If any of these are more important, how can we recognise this in the appraisal process?
And, how are trade-offs to be made? Is an option where 300 people’s journey’s made 10 minutes worse, the same as an option where 30 people’s journey’s are made 100 minutes worse?
4.5 Other issues
Accessibility is not a static concept. New roads, new bus routes and particularly Tramlink extensions could all change the picture.
We propose to deal with this by ‘sensitivity testing’. We need to test to what extent we should be prepared to score options on the basis of transport as it may be by 2010. That is to say to rank the options on current information, and then calculate how much changes to different transport there would have to be to alter which option ranked best.
Although we intend to look at three main options, we will also calculate the optimal location. Our current expectation is that this would be impossible to achieve in an area as densely populated as this. However, it would be possible, during the consultation period, to explore the possibilities of acquiring this theoretical site should there be compelling reasons to pursue this as an option.
5 Recruitment and retention
5.1 Definition
The ability to attract and retain good quality staff based on the site.
5.2 Some context and explanation
This is an important criterion. Staff recruitment and retention is a major issue, and increasingly the NHS is operating in a global market with US recruitment fairs being held in London to tempt nurses and others to the USA. There is free movement of labour within Europe and increasing competition to recruit from places such as the Philippines. Within the UK, various Trusts have added non-pay benefits, such as staff crčches and subsidised housing.
5.3 How this will be evaluated
Local Care Hospitals We will propose a network based on population clusters. We will suggest to the panel that they question Human Resource Directors as to whether any change to the proposed network would markedly affect our ability to recruit and retain.
Critical Care Hospitals We will ask Human Resource Directors to report on the current recruitment and retention statistics for each site, to see whether there is any significant difference. All other things being equal, a site which offers better prospects of staff recruitment is to be preferred.
5.4 Question
What future factors do we need to think about? Some are special to the NHS – such as the impact of new pay arrangements (Agenda for Change) which may alter the relative attractiveness of sites for staff. Some are external, such as housing growth (which might increase the labour pool).
6 Deliverability – Technical
6.1 Definition
The technical factors that make it more or less likely that any option can be brought to fruition.
6.2 Some context and explanation
There are a number of factors that influence the ease of completing a building programme. These will include:
· Planning issues (e.g. height/density restriction)
· Adequate provision for utilities – gas, electrics etc.
· Assembling the site – do we have square meterage and site capacity required and if not, how easy would it be to acquire?
· Buildability – do we have access to a clear site or do we have to build on a site that is fully functioning during building work? If so, how easy is it to decant the site prior to or during building?
· Amount of dual running required.
· Access for contractors’ vehicles.
· Physical nature of the site – for example is it on a hill? Are there drainage problems etc?
6.3 How
this will be evaluated
Local Care Hospitals We will propose a network of Local Care Hospitals based on population clusters. The primary purpose of the appraisal in June 04 is to confirm that these are the right population clusters.
At this stage the evaluation by the panel is around whether there are any substantial technical blockages to developing a network.
Critical Care Hospitals Each site warrants a presentation on all the relevant factors, together with an assessment of how easy/difficult it would be to overcome problems.
6.4 Comment
1 There is some element of subjectivity in this – we are seeking opinions. The opinions must be offered by qualified professionals, with professional standing: and they must state what evidence/experience leads them to that views.
2 We need to avoid double-counting. For instance, should a technical view be presented about road access, when we already have a criterion on accessibility.
3 We have not suggested any criterion for deliverability of a non-technical nature.
7 Strategic fit
7.1 Definition
How well the site and resultant delivery of the care model fits with the strategic plans of neighbouring organisations and the impact of one with another.
7.2 How this will be measured
Analysis of case load.
Exploration of strategic plans by SHA leads.
7.3 Context and explanation
This criteria is a standard requirement in OBCs. The DoH require the relevant Strategic Health Authorities to confirm that any project is not being submitted in isolation from what’s going on elsewhere, and in a way that would adversely impact some other Trusts’ plans. At a strategic level, it is for the Planning Directors of each Strategic Health Authority (who are on the Project Board) to confirm that other plans do fit.
But at an operational level, we must have some regard to the impact of this project. Whatever the location of the Critical Care Hospital, there will be some diversion of patients. (A&E attendees, admissions, maternity cases) to other hospitals. Such a diversion may be either negative or positive. Negative if it adds a burden with which they are unable to cope; positive if it adds to their long-term viability.
Their views will, therefore, be sought in the consultation period.
8 Partnership
8.1 Definition
The extent to which each option enables the public services to work together to support and sustain good services.
8.2 Some context and explanation
All other things being equal, a preferred option is one that supports integrated working.
8.3 This is not just about GPs and Hospital Doctors, but also about Therapists, Social Workers, Mental Health Services; indeed, all the parts of the public services that would be better for co-location. In this context “better” might mean for patients directly as part of a “one-stop” services, or better through co-located professionals sharing and learning.
8.4 How this will be evaluated
Local Care Hospitals Most of the partnership working would be addressed here. We will propose a network of Local Care Hospitals situated to serve population clusters. We assume that these are the same population clusters that other public services look to serve – but the panel will seek evidence to ensure that this is so.
Critical Care Hospitals Where the Critical Care Hospital siting would permit co-location with other NHS facilities (a Local Care Hospital, the Royal Marsden) it would create the opportunity for positive partnerships. The panel will take this into account in evaluating sites against the criteria.
9 Impact on the community
9.1 Definition
What impact will development of each site have on the local community.
9.2 Some context and explanation
All developments, whether housing, retail or NHS, have an environmental impact such as traffic (noise and pollution) – both in the construction phase and the operational longer term. All developments will also have an economic impact – providing local jobs and the potential for staff to spend money in local shops.
9.3 For the most part these impacts are taken into account on the premise of gaining planning consent (part of the “deliverability” criteria). But there may be issues which planners are unable to take into account with the strict legal framework of planning law, that the NHS would want to.
These impacts could be negative or positive. For instance, economic impact – providing local jobs, staff spending money in local shops or overspill parking on residential roads.
9.4 How this will be evaluated
Local Care Hospitals We will propose a network of Local Care Hospitals situated in population clusters. In most instances this will involve existing sites getting busier. What the panel will need to do is to assess whether the benefit of having a local facility might be outweighed by any negative environmental impact on any particular area. If so, then the panel might propose to omit that Local Care Hospital from the network.
Critical Care Hospital We will need to estimate footfall and vehicle movements for the Critical Care Hospital, and assess whether that would change the character of an area. We would also need to estimate employment – in some areas this would be a positive (more jobs for local people), in others it might be a negative (more vehicle movements from staff).
10 Flexibility/Robustness
10.1 Definition
How well each option could cope with potential changes in technology, models of care and changes to medical practice.
10.2 Some context and explanation
This will be a major investment of public funds. The future is by definition uncertain, and the rate of change in medical practice and technology is rapid. The policy context (patient choice and payment by results) adds to that complexity. All other things being equal, sites which offer the potential to accommodate changes after the opening date are to be preferred to those which do not.
10.3 How this will be evaluated
Local Care Hospitals We will propose a network of Local Care Hospitals situated in population clusters. The evaluation of flexible/ robustness would need to reflect views on how likely these population clusters are to remain – and how likely new clusters might emerge.
Critical Care Hospital Most flexibility will derive from building design and layout, regardless of the site location. But there may be sites that offer greater potential for expansion (or contraction) by the nature of their site layout.
10.4 Comment
Decentralisation to Local Care Hospitals may reduce flexibility. For instance, a distributed network of smaller day surgery units is unlikely to have the same flexibility in managing a theatre list as one larger day surgery unit.