Feature / The transformers

The NHS is regularly told it must transform the way it provides services – where they are delivered, how they are delivered, who they are delivered by and even how they are commissioned. This is not just a financial imperative, given the estimated £30bn savings required by 2020/21, but it must be done to improve clinical outcomes and address the needs of an ageing population with multiple morbidities.

Transformation projects are being developed and implemented across the NHS. For example, NHS England is reviewing how it commissions specialised services. Its planning guidance for 2014/15 to 2018/19 says it will look to reduce significantly the number of providers. While still in the early stages of development, its strategy could see providers reduced from around 200 to between 15 and 30, supported by a network of other providers, within the next four years. Such a move would have a national impact, but change at the local health economy scale is also being planned for.

In March, health secretary Jeremy Hunt gave Mid Yorkshire Hospitals NHS Trust and its commissioners the green light to implement its Meeting the challenge programme. This will shift more care into the community, with more clinics and less complex operations performed in the community. Urgent and emergency care will be reorganised, with one of its three hospitals – Pinderfields in Wakefield – seeing all major emergencies. The other two, Dewsbury and Pontefract, will have a team of emergency care doctors and nurses treating non life-threatening conditions; consultants in hospital during the day and on call; and staff with the skills to resuscitate people on hand 24 hours a day, seven days a week.

Surgery is offered at all three hospitals currently, but under the changes, most complex, emergency and major surgery would take place in Pinderfields, with most elective work at Dewsbury, and eye and orthopaedic surgery at Pontefract.

Trust finance director Robert Chadwick says change was prompted by financial and clinical factors. ‘The trust had a material underlying recurrent deficit, so the challenge was to review organisational viability and the ability to provide sustainable services that were safe, affordable and provided for an improved patient experience,’ he says.

A review was commissioned and it was concluded the trust could achieve sustainable services by delivery of a challenging cost-efficiency programme year-on-year, built on a radical clinical reconfiguration. He adds that the trust’s approved financial plan for 2014/15 is for a deficit of £17.1m. The trust will return to surplus in the 2016/17 plan. The clinical services reconfiguration will require significant capital investment at Pinderfields hospital and Dewsbury Hospital of £22m.

In many areas, transformation appears to be focused around changes in urgent and emergency care provision, but have a more widespread effect. In Calderdale and Huddersfield, clinical commissioning groups have reached a key stage in a strategic review that they say is about more than A&E.

Local providers, including two foundations and a local authority, have produced their proposals on the future of hospital and community services across Calderdale and Greater Huddersfield.

Calderdale model

They propose a new model for the provision of care in the area. Integrated teams of health and social care professionals would work together in a number of localities to provide as much care as possible outside hospital and closer to where people live. They would support people to take maximum responsibility for their own care and wellbeing. Acute and emergency services would be based at one specialist hospital site and planned and elective care on a second specialist planned care hospital site.

The publication of the providers’ proposals generated a lot of concern locally that the future of local hospitals had already been decided, but the CCGs insist no decisions have been taken. They are now engaging with local stakeholders before a full public consultation, which is likely to take place this summer.

Northumbria NHS Foundation Trust also plans to have dedicated emergency and elective units, but rather than splitting the responsibilities between existing hospitals, it has chosen to build a new emergency care hospital.

The Northumbria Specialist Emergency Care Hospital is currently under construction and is due to open next year. The trust says it will be the first in England to have emergency care consultants on site 24 hours, seven days a week. As well as a state of the art A&E department, the new hospital will have hi-tech diagnostics, critical care, a short-stay paediatric unit and a consultant and midwife-led maternity unit.

The new hospital is part of a 10-year, £200m-plus programme to build the new facility, rebuild two of its community hospitals and then develop the existing two largest district general hospital sites to move from six-bedded bays to four-bedded bays with ensuite facilities. Overall, this is a bed-neutral development and the 210 beds at the new facility will be matched by the reduction in beds on the other sites as the work progresses.

Funding is coming from a £50m loan from the Independent Trust Financing Facility. The rest will be sourced from the sale of surplus assets, retained depreciation, efficiency gains and retained surpluses.

There will be no changes to the tariffs paid once the new emergency hospital is up and running. ‘It will be the same patients, the same care just delivered on one site rather than three,’ medical director David Evans says. ‘We anticipate much reduced lengths of stay, avoidance of unnecessary admissions and overall a much more effective, efficient and streamlined patient experience.’

Mr Evans says the idea came about as part of the trust drive to improve the safety and quality of its services. ‘It was obvious that to continue to develop we had to move from a three acute site model and concentrate our expertise,’ he says.

Although the trust has had seven-day working by consultants in emergency care for more than 10 years, this had been organised so that clinicians were working generically as a physician or surgeon, rather than to their specialism. The consolidation of medical staff on one site will allow for an increased range of specialty presence over seven days.

‘Only by moving three into one can we realise what will be nine consultant teams working to their true specialty, with the whole driven at the front door by 24/7 resident emergency care consultants supported by acute care physicians,’ he adds.

The change will transform the way people are seen and they will be assessed by a consultant-led team early in their care, he says. ‘We knew that 84% of our admissions had a length of stay of 72 hours or less. These are often waiting for a test or to be seen by the correct speciality consultant. For a large proportion of these people, we can dramatically shorten this time and improve the quality and safety of their care.’

There will be a very small amount of elective surgery at the new hospital – probably no more than 100 cases per year. This is because all of the trust's ITU beds will be on the new site, so the small amount of surgery that requires a booked ITU bed will be done there. This is mainly major joint revision work and some large bowel resections.

Based on its current workload, the trust anticipates seeing 80,000 patients at the new emergency hospital each year, which will generate about 35,000 admissions.

The Northumbria trust consulted the community extensively, holding meetings since 2009, while there has been a full-scale consultation led by its commissioners. It has also ensured governors have been involved in providing information to the wider public, while regular supplements in local papers have kept the public informed of progress.

Mr Evans says the consultation was not a difficult process and was worthwhile and informative. ‘We were told this was the biggest public consultation the NHS had ever run,’ he says. ‘At times, we had up to three teams out each day at public meetings across the whole of Northumberland, as well as newsletters, questionnaires and a website. We learned a lot and at the end received 78% unqualified support for the proposal with further qualified support.

‘I certainly learned a lot about the view particularly of our most rural population about how they viewed the difficulties of accessing emergency care.’

Mid Yorkshire also consulted extensively and Mr Chadwick says finance staff were encouraged to engage in the public consultation. Many live near the hospitals affected. Finance staff were also involved in internal briefings.

‘Finance staff have a key role in messaging the need for clinical reconfiguration, why this is necessary and what the benefits are,’ he says. ‘The key message established was that the provision of sustainable services to the local population was the primary driver in the clinical services reconfiguration.

‘To achieve sustainable services that are safe and provide a good patient experience, the provision must be affordable with the resources available. The NHS is facing a significant financial challenge over the coming years; there are no exceptions or exemptions. Essentially ensuring an affordable clinical offering is provided for is the only way of ensuring sustainable services for the future.’

The Northumbria transformation has taken more than 10 years of detailed work and planning before the trust was in a position to submit its proposals. Mr Evans believes the notion of a separate, new build hospital could be a viable solution for other areas – though he adds that those following the Northumbria model could probably do it quicker.

However, King’s Fund head of policy Richard Murray believes that, while essential, transformation in the NHS will not be a quick process. ‘You need time to do it because it should be built on engagement with patients and the public. Sometimes in service transformation the public disbelieves us and you can understand that because of the speed with which we try to do it.’

In these cases, it can be difficult to convince the public that improving the quality and safety of care, rather than saving money, is the motive for the changes.

Financial argument

Attempting changes at a time when the NHS is facing such huge financial challenges makes it hard for those seeking to convince the public that it is not financially driven. International evidence suggests running the new service alongside the old one for a while can help convince patients of the case for the new service, Mr Murray says, though he accepts economic conditions make this difficult.

‘Maybe the service has come to this late in the day, but you have got to remember that deficit reduction was not supposed to go on this long, QIPP was supposed to end in 2014 and the money to start flowing again.’

As other areas bring forward transformation schemes, it is clear that collaboration between clinical, operational and finance staff is needed to help gain the trust of local people and politicians. The latter appear convinced of the need for transformation. A recent NHS Confederation survey said almost half of MPs believed it necessary to ensure services remain free at the point of need, with 81% believing services in their constituencies had to change.

Tellingly, 25% said they would not back changes if their constituents were opposed to them and 65% said there was not enough political will to drive through change. For NHS staff trying to transform their local services, it could be a long road.