Health for north east London JOSC and JJCPCT update 12 Oct 2010

Provide an update on the clinical work to review proposals for change Set out next steps to decision-making and how we are addressing the four reconfiguration tests

Four tests 1.Support from GP commissioners and GPs affected by the changes 2.Demonstrate robust public and patient engagement 3.Clear clinical evidence base (and support from hospital clinicians affected by the changes) 4.Understanding of the impact of the changes on patient choice (and demonstration that new arrangements offer choice, as appropriate) NB: NHS London will provide external assurance in relation to the extent we have met four tests

Clinical review of proposals CWGs reviewed consultation feedback Series of clinical and stakeholder engagement events CWG events: scheduled care, unscheduled, maternity and newborn care, children and young people Clinical discussion forum Stakeholder briefing Each CWG has developed a report updating recommendations to support decision-making. These will be published in draft this week and finalised over the coming weeks We are currently developing supporting materials for pre decision-making phase of engagement. (Summary report, localised reports for PCTs and boroughs, FAQs etc)

Summary of clinical review Endorsed proposal to reduce number of hospitals in north east London providing full A&E, 24/7 paediatrics, acute medical and surgical care and obstetric deliveries; and supported the move from six to five Endorsed proposal to develop King George Hospital, Ilford as a hospital with 24/7 primary and urgent care and an extensive range of planned care services Proposed strengthening urgent and emergency care services to be offered at King George Proposed strengthening model of care for maternity services Endorsed proposals for children’s services (with some amendments)

Summary of consultation issues Concern related primarily to changes to A&E and acute pathway chances and maternity Planned care and paediatric changes broadly supported Key concerns: Travel and access (traffic conditions, public transport links to Queen’s, car parking) Capacity and resilience (current services struggle to manage demand) Quality and patient experience – e.g. size of maternity unit at Queen’s

Urgent and emergency care Stronger urgent and emergency care in all A&E hospitals Strengthen urgent care services on all sites – should be able to manage minimum 50% of current A&E and UCC attendances (currently 30 – 40%) KGH to have 24/7 primary and urgent care including GP out-of-hours – polyclinic hub Develop short stay assessment and treatment service for adults and children at KGH Workforce strategy Better signposting and communication

Short stay assessment and treatment Assessment and treatment of patients with needs that are more complex than can be managed within UCC but not expected to need inpatient admission. Diagnostics, observation, treatment, follow up care arranged Staffed by skill mix team of senior clinicians, drawing on both primary care and emergency medical skills (shared posts with local A&E teams). Rapid access to specialist advice Initial assessment of all ‘self presenting’ patients making sure directed to most appropriate service for their care, including safe and effective transfer of patients needing A&E care to an A&E hospital. (NB most patients requiring A&E or admission will be referred direct by LAS / EAS / their GP) Responsible for stabilising acutely unwell patients prior to transfer Open 24/7 but patients expected to stay 12 hours or less

Maternity services Develop five ‘maternity campuses’, emphasis on midwifery- led care, ‘core offer’ described. Each campus to offer full range birth settings (obstetric, alongside midwifery-led unit (MLU), home birth; and access to a free-standing MLU) Aim for 24/7 consultant cover on obstetric units All additional Queen’s activity to be managed in new alongside midwifery-led unit Commitment to develop Barking Birthing Centre (freestanding MLU) MLU at KGH as part of transition to new model – review taking into account level of demand and geographic proximity to Barking

Making midwifery-led care the default option 10 Obstetric-Led Unit Key Out of hospital birth Alongside Midwifery-Led Unit Activity flow Woman/baby Home 5-10% Home 5-10% Free Standing Midwifery- Led unit 5-10% Free Standing Midwifery- Led unit 5-10% Obstetric- Led Unit 60% Obstetric- Led Unit 60% Alongside Midwifery- Led Unit 30% Alongside Midwifery- Led Unit 30% Campus model 60% births in team setting (midwife, anaesthetist, obstetrician) 30% births in alongside midwifery-led unit 10% Out of hospital births split 50:50 home / free standing midwifery-led unit 60% births in team setting (midwife, anaesthetist, obstetrician) 30% births in alongside midwifery-led unit 10% Out of hospital births split 50:50 home / free standing midwifery-led unit

A&E Fetal Medicine Unit Antenatal clinic Triage Delivery Day Assessment Unit Obstetric Led Unit (60%) Alongside MLU (30%) Home (5-10%) Free standing MLU (5-10%) Children’s centre Blood tests Screening & Ultrasound Breastfeeding support Day Assessment Health Centre/Polyclinic GP Booking Helpline Antenatal Postnatal NICU HDU Emergency Gynae Triage Early Pregnancy Unit Maternity services Acute setting Community setting Activity flow Woman/baby Key Model of care for maternity and newborn services

Current model – current flow across six sites 7000 (20/day) 5000 (14/day) 5000 (14/day) Queen’s Whipps Cross Homerton BLT Newham 3000 (8/day) 4700 (13/day) 4700 (13/day) 400 (1/day) 400 (1/day) 4200 (11/day) 4200 (11/day) 4100 (11/day) 4100 (11/day) 30 King George (1/day) 400 (1/day) <1000 (3/day) <1000 (3/day) 90 ( 0.2/day) 90 ( 0.2/day) 40 (0.1/day) 40 (0.1/day) 50 (0.1/day) 50 (0.1/day) 150 (0.4/day) 150 (0.4/day) 100 (0.3/day) 100 (0.3/day) 1000 (3/day) 1000 (3/day) Obstetric Led Unit births/yr Key Home births/yr Alongside Midwifery Led Unit births/yr Free standing Midwifery Led Unit Births/yr

Future model: current flows across five campuses 6700 (18/day) 4300 (12/day) 4300 (12/day) Whipps Cross Homerton BLT Newham 3100 (8.5/day) 3100 (8.5/day) 400 (1/day ) 400 (1/day ) 3200 (9/day) 3200 (9/day) 4440 (12/day) 4440 (12/day) 700 (2/day) 700 (2/day) BHRUT Obstetric Led Unit births/yr Key Home births/yr Alongside Midwifery Led Unit births/yr Free standing Midwifery Led Unit Births/yr (6/day) 2200 (6/day) 1500 (4/day) 1500 (4/day) 500 (1.4/day) 500 (1.4/day) 140 (0.4/day) 140 (0.4/day) 720 (2/day) 720 (2/day) 600 (1.6/day) 600 (1.6/day) 500 (1.4/day) 500 (1.4/day) 2220 (6/day) 2220 (6/day) 3300 (9/day) 3300 (9/day) 1600 (4.4/day) 1600 (4.4/day)

Redirecting flows -travel times to selected wards 14 Example: Clayhall BHRUT is currently the main provider But average journey-time to Queen’s is 22 Minutes Whereas journey time to Whipps Cross is 15 minutes

Future model: equalised flows across five campuses 5100 (14/day) 5100 (14/day) 5100 (14/day) Whipps Cross Homerton BLT Newham 400 (1/day) 400 (1/day) 3300 (9/day) 3300 (9/day) 4800 (13/day) 4800 (13/day) 850 (2.3/day) 850 (2.3/day) BHRUT (7/day) 2550 (7/day) 550 (1.5/day) 550 (1.5/day) 150 (0.4/day) 150 (0.4/day) 800 (2/day) 800 (2/day) 450 (1.2/day) 450 (1.2/day) 400 (1/day) 400 (1/day) 2400 (6.5/day) 2400 (6.5/day) 2550 (7/day) 2550 (7/day) 1650 (4.5/day) 1650 (4.5/day) Obstetric Led Unit births/yr Key Home births/yr Alongside Midwifery Led Unit births/yr Free standing Midwifery Led Unit births/yr 3300 (9/day) 3300 (9/day) 1650 (4.5/day) 1650 (4.5/day)

Choice in maternity services We have commissioned independent external support to undertake a series of focus groups with local women to better understand: extent to which current service model offers choice what effects women’s choices choices local women would like how local women feel the proposed changes to maternity services would impact on choice

Children and young people Clinicians endorsed proposals with some minor amends Build on Barts and London Hospital current role as specialist paediatric centre Develop services at Queen’s so that as many children and possible can have their care needs met locally Endorsed proposal for 24/7 paediatric care on all A&E sites, including inpatient care, with separate facilities for children Key principle: ambulatory philosophy which is underpinned by senior clinical decision-making early in pathway, and individualised assessment of children

When to transfer children? Children with specialist and high dependency care needs to be transferred to specialist centre – decisions based on individualised assessment of child (i.e. not based on expected length of stay, clinical guidelines to be developed) All surgery on children aged two and under at BLT (exceptions: simple ophthalmic surgery, simple surgery on neonates at Homerton) Urgent / complex surgery on children aged 3 -15: detailed protocols developed setting out when to transfer children and when can be treated locally. All sites must demonstrate can meet required standards More care retained locally than originally anticipated

Children’s services at KGH King George Hospital would no longer provide A&E or inpatient care for children – children needing this level of care would need to be transferred to Queen’s, Whipps Cross or Newham hospitals KGH would offer: 24/7 urgent care and short stay assessment with expertise in care of sick children Paediatric outpatients (extended range, including same day / next day access) Child Health Centre – specialist child health including neuro-disability, CAMHs, therapies, safeguarding children’s services

Scheduled care Endorsed principle of separation (same site / different site) Detailed work to describe surgery that is suitable for planned care centre setting vs surgery that needs to be located on A&E hospital site Endorsed proposal to develop ‘centre of excellence in planned surgery at KGH’ Renal dialysis to be provided at KGH Cancer day care to be retained at KGH (Cedar Centre)

King George Hospital – the vision 24/7 urgent & primary care Short stay assessment and treatment Child health centre Diagnostics Surgical centre Renal dialysis Outpatients & long term conditions Maternity day care Cancer care & chemotherapy

GP commissioning and practice engagement Health for north east London team working with GP commissioning leads to ensure we have a robust understanding of level of support for proposals across primary care, including issues of concern Meetings arranged with GP commissioning groups, PECs, CECs, LMCs etc process culminates: 17 November clinical reference group, 19 November INEL Clinical Commissioning Board, 30 November ONEL Clinical Commissioning Board

Stakeholder and local authority engagement Agreed ‘tailored’ engagement programme with each local authority – Cabinet and / or OSC JOSC meetings convened and Health for north east London has offered to support additional meetings as required Updates / opportunity to comment: People’s Platforms and LINKs Other interested organisations invited to feedback through the above organisations or at

Engagement materials Available from 15 Oct Overview paper, borough-based summaries and presentations Clinical Working Group ‘working draft’ reports Draft of decision-making business case chapter on activity and capacity FAQs

Decision Making Business Case 1.Updated clinical case for change, final clinical proposals, links to Commissioning Strategy Plans (CSPs) and whole system change, impact on patient choice, expected benefits 2.Activity, capacity, finance including I&E impacts, capital and transition costs 3.Implementation including phasing change, ‘gateways’ and workforce implications 4.Summary of evidence against the four tests 5.Outcome of NHS London assurance vs four tests

Joint JCPCT 15 December 2010 Papers published 8 December 2010 SHA review process – will run alongside business case development and engagement process in November. GP commissioning test assurance in early December