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Revised 19th May 2004
The objective of the Clinical Services
Strategy is ‘better care, closer to home’. 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
The detailed specification of what can take place in Local Care Hospitals and what must be done in the supporting Critical Care Hospital will be the product of clinical advice. There are a large number of clinical professionals who have been meeting regularly over the last year, and will continue to meet to refine these plans. We expect to publish their current best estimate as part of the Working Papers leading up to formal consultation.
The network of Local Care Hospitals will be sited to serve 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 September-November will invite people to comment on whether or not that network could be improved upon. In proposing the network of Local Care Hospitals, each PCT will have regard to the criteria set out here.
The
This document
sets out ten criteria against which the sites for a
These criteria are the result of an initial set of ideas published in March 2004 (as Working Paper 3), modified in the light of comments received, and by a workshop facilitated by an expert in public sector economic appraisals.
We have now taken the view that 3 of the initial set are ‘hurdle conditions’. That is to say they are important criteria that must be achieved before an option should even be considered. These are:
Fit with model of care
Quality
Service capability and national policies
They are not however criteria that would be scored differentially between options. A fourth ‘hurdle condition has been added – Education, Training and Research.
One criterion has been added. We have accepted the view from a number of commentators that, as far as it can be measured, we should take account of the differential impact each option might have on reducing the health inequalities in the population we serve.
Three criteria have been modified. Accessibility has been split into ‘blue light’ ambulance access and patient and visitor access. Technical deliverability has been split into planning considerations and technical deliverability (excluding planning considerations). Impact on the Community has been split into two parts: short term disruption (ie through building works) and long term (the ongoing impact on the local population).
We have also now taken a view as to the weightings to be applied to each criterion, which we are expressing as percentages out of 100%.
The purpose of weightings is to assist judgement between options. If an option were to be rated the best on all 10 criteria, it would have the best benefits overall and there would be no need for weightings. (Although there would still be a question to be addressed about affordability).
But a more common position in appraisals is that some options are best on some criteria, whilst other options are best on other criteria. Forming a view as to which is the best overall mix of benefits requires them to be weighted for relative importance.
The resultant criteria and weightings can be grouped under broad headings:-
n Quality
n Fit with model of care
n Service capacity and national policies
n Education, Training and Research
What is the right location?
1. Visitor and patient access
2. Blue light access
3. Staff recruitment and retention
Can it be achieved?
4. Technical deliverability (excluding planning considerations)
5. Planning considerations (likelihood of consent)
6. Strategic Fit
7. Impact on the community (short term disruption)
8. Impact on the community (long term)
9. Health inequalities
10. Future flexibility
This working paper sets out the way we are defining these criteria, which in turn leads to data being collected to evaluate the options against the criteria.
This is one of a series of Working Papers, which in time will underpin formal consultation from the beginning of September to the end of November 2004 – leading to a decision in January 2005.
Any comments on this Working Paper should be sent to Keith Ford (details below)
Any such response does not prejudice the rights of the individual or organisation to comment during the formal consultation phase.
Keith Ford
Programme Director
Better Healthcare Closer to Home Project
Room 32, Rowan House
Epsom Hospital
Dorking Road
Epsom Surrey
e.mail; betterhealthcare@epsom-sthelier.nhs.uk
All sites would be expected to reach minimum standards as regards:
Quality – Each site needs to be capable of accommodating a building designed to a quality standard environmentally, and designed to deliver services in a high quality manner.
Fit with model of care – Each site option needs to support the model of care which provides a network of Local Care Hospitals supported by a Critical Care Hospital.
Service Capacity and National Policies – Each site needs to be capable of being developed to the capacity required to deliver national policy targets.
Education, Training and Research – Each site needs to be capable of supporting patient and staffing levels commensurate with carrying out good quality education, training and research.
Our current view is that all the site options have a large enough ‘footprint’ to meet these conditions. We do not propose to collect specific data to discriminate between sites on any of these conditions.
1.0 Visitor and patient access – weighting 14%
1.1 Definition
The journey time taken by patients and their visitors to attend the single critical care hospital.
1.2 Some context and explanation
Patient journeys will be for those who require scheduled inpatient care or who attend accident and emergency other than in a blue light ambulance. Visitor journeys will be those related to the patient attendance.
1.3 How this will be evaluated
Journey times will be estimated from the centre of each of 120 postcode sectors (capturing the majority of patients currently attending the Epsom & St. Helier University Hospitals NHS Trust) to various site options for the critical care hospital.
These times will be split by public transport and private transport, adjusted for percentage car ownership and population density in each postcode section.
The sites will therefore be compared one with another with relative ease of access for non-blue light attendances to the critical care hospital.
1.4 Comments
Accessibility is not a static concept. New roads, new bus routes and Tramlink extensions could all change the picture.
We intend to use current transport routes in this appraisal, and discount infrastructure still in the planning stage. However, we will undertake ‘sensitivity testing’. That is to say to rank the options on current information, and then calculate how much improvement in 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.
We are aware that the cost of public transport varies in different parts of the catchment area. However we do not believe that the location of an NHS facility should take this into account. This would require a sub-optimal investment decision by the NHS to redress different policy decisions on investment by transport authorities.
2.0 Blue light access – weighting 15%
2.1 Definition
Patients who are taken to the critical care hospital in an ambulance under blue light (emergency) conditions. This will exclude those who attend in an ambulance but not under emergency conditions.
2.2 Some context and explanation
Around 20% of patients attend the A&E by ambulance. For most patients, the critical time dimension is the speed of ambulance attending scene – hence targets set by DoH for this of 8 minutes. The most critical factor is the seniority and experience of the clinicians available on arrival at A&E. For this reason some patients bypass the nearest hospital in favour of a unit with specialist in neurosurgery, burns or trauma.
The speed of transmission to the nearest A&E is not normally a critical factor. In around 5% of ambulance journeys (1% of all attendances) the crews deem it desirable to use ‘blue lights’ to aid their passage through the traffic. Where time is a critical factor, the phrase ‘golden hour’ is often used – conventional wisdom is that intervention by a doctor within one hour of the injury/trauma is highly desirable.
The overall patient time from injury scene to A&E door is not likely to breach an hour due to a single critical care centre as opposed to two A&E departments. Nevertheless, all other things being equal it is preferable that a location which keeps ‘blue light’ journey times to a minimum is to be preferred.
2.3 How will this be evaluated?
We will aim to analyse which site minimises the travel time from the post code sectors in the catchment to an A&E department., weighted by the number of people in each post code sector.
This acts as a proxy for the probability of a ‘blue light’ ambulance being required to travel from that post code sector. We shall seek the views of the relevant ambulance services as to whether any post code sector has a higher probability of requiring ‘blue light’ ambulance for reasons other than population density (eg traffic problems, industrial or retail complexes)
Our analysis will take account not only of those patients who will be taken to the critical care hospital, but also those taken to alternative sites. It therefore seeks to measure the optimal location for the whole catchment population.
3.0 Staff
Recruitment and retention – weighting 10%
3.1 Definition
The ability to attract and retain good quality staff based on the site.
3.2 Some context and explanation
Staff recruitment and retention is a major issue, and increasingly the NHS is operating in a global market with, for example, 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.
Issues such as training, education and research will all be important factors in helping to recruit and retain staff. The location of site and the network of local care hospitals could contribute to the success. In addition, the way the network overall works will have a major impact on the roles undertaken and therefore the quality of the jobs offered.
3.3 How this will be evaluated
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 that offers better prospects of staff recruitment is to be preferred.
3.4 We will examine current data. Although there are potential changes to the pay structure (so called Agenda for Change) we do not consider it will be significant in altering the relative balance between sites.
4.0 Technical deliverability (excluding
planning considerations) – weighting 13%
4.1 Definition
The technical factors that make it more or less likely that any option can be brought to fruition.
4.2 Some context and explanation
There are a number of factors that influence the ease of completing a building programme. These will include:
· Assembling the site – do we have square meterage and site capacity required and if not, how easy would it be to acquire?
· Adequate provision of utilities – gas, electrics, water etc.
· 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?
· Access for contractors’ vehicles.
· Physical nature of the site – for example is it on a hill? Are there drainage problems etc?
· Timescale – different site options may have different timescales depending on the complexities
4.3 How
this will be evaluated
Each site warrants a presentation by qualified professionals on all the relevant factors, together with an assessment of how easy or difficult it would be to overcome problems.
5.0 Planning
issues – weighting 12%
5.1 Definition
An assessment of the probability of the design concept being able to proceed through the planning process without modification, without restrictions or caveats, and without delays through negotiations or appeals.
All other things being equal, a site with a smooth passage is to be preferred to one where difficulties would ensue.
5.2 Some context and explanation
All development will need discussion with Planning Authorities. At this stage it is an assessment of the probability of problems, which would be presented.
5.3 How
will this be evaluated
The Planning Authorities themselves might present their views but this may be seen as prejudicing the outcome of the planning process. Alternatively the professional advisers to the project will present views based on their discussions and interpretations of published planning guidelines.
6.0
Strategic fit – weighting 10%
6.1 Definition
How well each option fits with, and contributes to, the strategic direction of service plans drawn up by Primary Care Trusts for the residents of the area.
How well each options fits with, and contributes to, the strategic directions of the plans of neighbouring NHS Trusts.
6.2 Context
and explanation
PCTs are responsible for the direction of service plans in their area. The DoH requires that Business Cases have explicit confirmation that they are being developed in line with PCT plans.
In this case the PCTs are contributing to both the concept and implementation of the programme.
The principal issue for appraisal is whether any different potential location for the CCH is a better fit than any other with PCT plans.
6.3 How this will be measured
PCTs will provide a commentary on each option, as regards local residents interests.
The plans of neighbouring Trusts ought also to be consistent with the service plan of PCT’s, and in that sense it is for PCT’s to ensure that individual Trusts plans fit together.
However, it may be that there are aspects of individual
Trusts plans which go beyond the direct interests of local residents (e.g.
Education, Training and Research). Local
Trusts will be invited to comment on this, in particular if any site location
offers a better fit than another.
7.0
Strategic fit – weighting 10%
7.1 Definition
The impact the development of each site will have on the local community during the short term construction phase.
7.2 Some context and explanation
All developments, whether housing, retail or NHS, have an environmental impact during the construction phase. This can manifest itself as increased heavy traffic (noise and pollution), noise of building, antisocial aspects of building such as dust, and potential disruption to local services – for example short term cutting off of utilities (water, gas, electricity).
7.4 How this will be evaluated
For the most part these impacts are taken into account in conditions attached to planning consent for the eventual option.
However, we will also appraise sites explicitly against this criterion ourselves – using our professional advisors – prior to the selection of an option and submission of a planning application
8.0 Impact on community (long term) –
weighting 6%
8.1 Definition
The impact of the presence of a Critical Care Hospital within a particular area, on the residents of that area.
All other things being equal, an option perceived by local residents as having a positive impact is to be preferred to one perceived by local residents as having a negative impact.
8.2 Some context and explanation
All developments will have an impact. These impacts could be positive or negative. For instance, positive economic impact such as providing local jobs and staff spending money in local shops; negative environmental impact such as overspill parking on residential roads and the effect of people, staff, patients, ambulances and visitors, travelling to the site.
8.3
How will this be evaluated
We will aim to estimate footfall and vehicle movements for the Critical Care Hospital. With this information at appraisal stage we would seek views from local councillors as community representatives as to whether the presence of a Critical Care Hospital would be viewed positively or negatively. During the formal consultation period, the direct views of local residents be sought.
9.0 Health
Inequalities – weighting 5%
9.1 Definition
The contribution that each site makes to reducing the health inequalities of the population.
9.2 Some context and explanation
In using this criterion, there is a presumption that the location of the critical care hospital will improve the health of deprived or sick people more by being located close to areas of relative health need.
This is not about the ‘draw’ effect a critical care hospital will tend to exert by increasing attendances the closer the patient is to the site.
9.3 How will this be evaluated
A literature search will be undertaken to identify any research that supports the presumption, and the views of public health professionals invited.
Geographic mapping of areas of health inequality will be available.
10 Future flexibility – weighting 10%
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 that do not.
10.3 How this will be evaluated
Most flexibility will derive from building design and layout, regardless of the site location. However, there may be sites that offer greater potential for expansion (or contraction) by the nature of their site layout.
We will expect the professional advisors to comment.
REF:
Working Paper6.keithford.lgreening.doc