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Our Healthier South East London Planned Care Reference Group

Report from second meeting 16

th March 2016

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Document History Original author: Jill Mulelly, Engagement Lead, Our Healthier South East London 21/03/16

Revision date Author(s) Change summary Version*

25/3/16 Oliver Lake Proof reading V2

26/03/16 Peter Gluckman Consistency of terminology V3

30/03/16 Mark Easton No changes – factual accuracy agreed V4

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Contents

1. Executive summary ...................................................................................................................... 4

2. Introduction ....................................................................................................................................... 5

3. Methodology ..................................................................................................................................... 5

3. Programme ....................................................................................................................................... 6

4. Summary of event content and discussions ................................................................................ 7

4.1 Elective orthopaedics in south east London .......................................................................... 8

4.1.1 Summary of presentation .................................................................................................. 8

4.1.2 Expert panel question and answer .................................................................................. 8

4.2 South West London Elective Orthopaedic Centre (SWLEOC) ........................................... 9

4.3. Draft evaluation criteria and the committee in common ................................................... 10

4.3.1 Hurdle criteria. Are these the right ones? Have we left any out? ........................... 11

4.3.2 Second stage criteria. Are these the right ones? Have we left any out? ................ 13

4.3.3 Can you prioritise the second stage criteria – high, medium and low ................ 14

5. Next steps .................................................................................................................................... 14

Appendix 1 – Attendees .................................................................................................................... 15

Appendix 2 – Draft hurdle criteria .................................................................................................... 17

Appendix 3 – Draft second stage criteria ........................................................................................ 18

Appendix 4 – Feedback from the meeting ...................................................................................... 20

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1. Executive summary

This meeting builds on the first meeting of the Planned Care Reference Group (25th

March 2016) – which provided an introduction as to why the programme thinks that

these services need to change and explored some of our initial thinking around it.

The objectives of this meeting were to:

Provide a deeper level of detail about the challenges being faced and

evidence behind the suggested solutions

Discuss the South West London Elective Orthopaedic Centre (SWLEOC) –

how it was planned and how it works in practice to improve quality and patient

experience

Provide more information about how decisions will be made.

Twenty one people from across the six south east London boroughs attended the

meeting. There were representatives from each borough and from each of the

groups likely to be most affected by any change to planned care services.

Key points from the meeting:

First, there was recognition that this was an important project and the work should

continue. When discussing the decision-making process, we asked for comments

on the evaluation criteria. The areas that were emphasised by stakeholders were as

follows.

Transport should be considered in light of the individual needs of the patient

and their family members/carers. There was recognition that a single

specialist centre would increase travel times.

Social care before and after any operations needs to be integral to our

thinking because inevitably there would be several boroughs’ social care

departments linked to the planned care centre.

This project must not destabilise other local hospitals – they must remain

sustainable.

Change must demonstrate a strong financial case, and be capable of being

delivered in a reasonable time.

Finance should not trump quality when taking decisions.

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2. Introduction

Our Healthier South East London (OHSEL) is a partnership between the six NHS

Clinical Commissioning Groups (CCGs) for south east London – Bexley, Bromley,

Greenwich, Lambeth, Lewisham and Southwark – working with NHS England, local

provider trusts, local authorities, patients and members of the public to develop a

future strategy for health services in our area.

The overall aim of the programme is to improve the quality of services for local

people across the area.

We have been considering opportunities to improve planned orthopaedic

services. The planned care orthopaedic work stream is the only work stream in

which we are likely to develop proposals requiring public consultation.

3. Methodology

In order to help shape how plans are being developed for improving planned care

orthopaedic services, we formed a Planned Care Reference Group comprising key

voluntary and community sector stakeholders and patients and the public. The remit

and membership of this group was informed by discussions at the South East

London CCG Stakeholder Reference Group meeting held on 8th December 2015.

The Planned Care Reference Group held its first meeting on 25th January 2016. This

meeting was open to all interested parties from these sectors. Invitations were sent

to:

Local Healthwatch organisations

Voluntary and community sector umbrella organisations

Equality groups from communities who would be most impacted by any

changes to planned care services: older people; carers; people who live in

areas of socioeconomic deprivation; people with physical disabilities; people

with mental health conditions and people with learning disabilities.

Local campaign groups – including Keep Our NHS Public and Save

Lewisham Hospital

Patients and the public (recent service users – who were recruited through

word of mouth and via outpatient clinics)

People who expressed an interest, or attended the first meeting, were invited to

attend the second meeting of the planned care reference group.

The meeting was independently chaired by Peter Gluckman and facilitated by the

OHSEL communications and engagement team. Those present included the Senior

Responsible Officer for planned care (Sarah Blow), the Programme Director (Mark

Easton), Steve Thomas, (Director of SWLEOC), Paul Minton (Independent Chair of

the CCGs’ Committee in Common), Patrick Li (Consultant Orthopaedic Surgeon –

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Kings College Hospital) and Peter Earnshaw (Consultant Orthopaedic Surgeon

Guy’s and St Thomas’ Hospital). A full list of attendees can be found in Appendix 1.

Twitter was used throughout the event by programme staff and attendees. At the

start of the session attendees gave permission for the use of social media during the

event and for the taking of photographs.

Attendees were divided into three tables of approximately seven participants. Each

had an expert facilitator and a scribe (a member of the programme’s

communications and engagement team).

3. Programme

Topic Time

Introduction and welcome 0945

Elective orthopaedics in south east London • Why do we need to change planned orthopaedic care?

• What are we changing?

• How these changes could happen?

1000

Expert panel Q&A 1020

South West London Elective Orthopaedic Centre (SWLEOC) –

Presentation and Q&A 1035

Comfort/refreshment break 1100

Draft evaluation criteria and the Committee in Common (CIC) 1110

Table discussion 1125

Plenary 1210

Wrap up and next steps 1225

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4. Summary of event content and discussions

The meeting was formed of three topics: (1) why do we need to change planned

orthopaedic care; and (2) what are we changing; and (3) how these changes could

happen. This was followed by a question and answer session with Sarah Blow and

the two consultant orthopaedic surgeons.

We heard from Steve Thomas, director of the south west London elective

orthopaedic centre (SWLEOC) – to understand more about how their model was set

up and works in practice.

The meeting then looked at how decisions would be made regarding what options for

delivering planned care in south east London could go to public consultation. This

included an in-depth look at both the hurdle and second stage evaluation criteria.

All presentations are available on our website:

http://www.ourhealthiersel.nhs.uk/about-us/publications.htm

Before the presentations began, the chair provided a recap of the previous meeting

(25th January 2016).

Key points raised at the last meeting:

Overall, participants agreed that their experiences matched the challenges

facing local planned care services as highlighted during the meeting. However

there was a desire to know the data/evidence behind them.

People noted that they would be prepared to travel if there were more

certainty about the quality of their care (procedures not being cancelled,

higher quality services, more confidence in treatment given, better preparation

and aftercare).

When looking at future models of care the status quo should be included.

Careful consideration should be given to location of sites and transport/access

links.

Further work needed to ensure that IT systems are compatible across the

health and care system.

Suggestions for what to address at the next PCRG:

Provide a deeper level of detail about the challenges being faced and

evidence behind the suggested solutions.

Further information should be provided on SWLEOC, its effectiveness and

how its quality has been measured.

Provide information about how decisions will be made.

The importance of effective links to several social care departments

simultaneously be more demonstrably recognised in the planning process.

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4.1 Elective orthopaedics in south east London

4.1.1 Summary of presentation

As requested at the last meeting, Sarah Blow provided a more detailed case for

change. It was noted that no decisions about the future of planned elective

orthopaedic care had been made.

An important report is driving much of this work: Getting it right first time: Improving

the Quality of Orthopaedic Care within the National Health Service in England,

Professor T. Briggs, 2012.

“If orthopaedic services, within a certain geographical area and with an appropriate

critical mass were brought together, either onto one site or within a network… and

worked within agreed quality assurance standards, not only would patient care

improve but billions of pounds could be saved.”

It was noted that there are three main reasons why planned care services need to

change: 1) demand is going up 2) trusts are struggling to manage the waiting times

and 3) whilst length of stay has improved, it remains below the London average at

most sites in south east London.

The programme is exploring whether services could be improved by consolidating

elective inpatient services from the current eight sites into two sites - with

outpatients, day case and trauma services remaining local. The ambition is to retain

all of the current hospitals – and work collaboratively with existing providers to

deliver the new model of care (similar to the south west London model).

In order to do this, the programme is considering the following scenarios: status quo,

single site and two sites.

4.1.2 Expert panel question and answer

Attendees were invited to ask an expert panel questions about what they had heard.

Panel members:

Patrick Li (Consultant Orthopaedic Surgeon, King’s College Hospital)

Peter Earnshaw (Consultant Orthopaedic Surgeon, Guy’s and St Thomas’

Hospital)

Sarah Blow (Chief Officer Bexley CCG and Planned Care Senior Responsible

Officer)

Q: Has the training of junior doctors been considered?

A: It is true that regulations around working hours have had a difficult impact on how

much operating time trainee doctors have. However, within orthopaedics, it is

possible with careful planning to deliver concentrated training with the hours that you

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have. Consolidating services should help as it will increase volume and specialism –

in addition this model would stop operations from being cancelled.

Q: How would surgeons in district general hospitals gain the relevant experience?

A: The idea is that the elective centre (s) would be owned by all of the acute trusts.

It’s important for staff to work in local trauma services as well as in the elective

centre. The programme is proposing that surgeons and their teams follow their

patients.

Q: Patient had their hip replaced in Bromley – but due to waiting lists, they were sent

to the private sector to have it done.

A: We don’t support the concept of sending people to private institutions unless there

is not the NHS capacity to deliver the service. This happened more in the past when

waiting lists were worse. Elective centre (s) would remove the need to contract out to

private providers. At the moment we don’t have the capacity in the NHS to meet the

waiting lists.

Q: How close do facilities for emergency care need to be? For example, if a patient

has a heart attack on the operating table.

A: Rigorous pre-operative assessment helps to ensure that this doesn’t happen.

Overall, there is agreement that there needs to be a proximity set for high intensity

support – however – agreement has not yet been reached on the location/distance of

this support. This work continues.

4.2 South West London Elective Orthopaedic Centre (SWLEOC)

Steve Thomas, director of the South West London Elective Orthopaedic Centre,

gave a presentation on how that model of care was set up, and how it works in

practice.

It was noted that back in 2000, south west London was challenged by very long

waiting lists. People were waiting four to five years for an operation – and operations

were frequently cancelled due to emergency work taking priority. They decided to

consolidate services into one site – in Epsom. They knew that this meant that travel

would be a problem for people so they endeavoured to ensure that as much as

possible was delivered locally. SWLEOC is located next to Epsom Hospital – but is

run separately. The initial model was an opportunity to rethink the organisation of

services – focusing on quality, education and research.

Much of the care is nurse given, with extended scope of work. There is a consultant

intensivist on site 24 hours a day, seven days a week. That role is crucial.

It’s a partnership model, made up of the four local hospitals and managed by a

partnership board. The financial risk is shared across the hospitals and any surplus

is shared between them.

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Transport was recognised as a key problem. Their solution was to work with a local

taxi provider – to take patients to and from services as needed. If people lived alone,

the taxi person would also stop at the shops and buy them provisions on the way

home and settle them in back at home. Streamlining services give you the chance to

focus on the work in hand, not be distracted by other services and therefore be able

to deliver better work.

Q: What are the key elements of developing team work?

A: Planning is vital. In south west London, workforce planning took over two years.

At first there can be scepticism, but you can get buy-in by discussing the benefits

and improvements. It was noted that in south east London, we are already looking at

how to bring people together to talk about working together well in the future.

Q: Concerns have been raised about how this links in with social services – what are

the relationships like now?

A: It is essential to plan discharge even before people come in for their operations –

to ensure everything is in place when they are discharged. It was noted that pre-

planning is considered vital within the south east London discussions – and that an

elective centre would make planning easier to manage.

Q: We’ve heard good things about the south west London model. How much does

this cost?

A: When we started this service south west London was losing £7 million a year. The

first year we lost £4 million. This year we are making a surplus of 7-10% over and

above the NHS tariff.

Q: Is it possible to know how many patients were sent out to intensive care units?

A: We provide services to 5000-6000 people per year. Out of this, approximately six

people have had to be sent to intensive care units outside of SWLEOC.

4.3. Draft evaluation criteria and the committee in common

Paul Minton, independent chair for the south east London Clinical Commissioning

Group’s Committee in Common, introduced himself and the role of the committee.

He noted that there are some services that need to be considered on a regional

basis – and the six Clinical Commissioning Groups have come together to consider

these. Paul is the independent chair of this committee, with no vested interest in the

boroughs. His role is to ensure that the process of decision-making is fair.

The first meeting of the Committee in Common is on the 17th March 2016 (the day

after this event) and the first substantive item is about planned care. The committee

is being asked to sign off: (1) the case for change; (2) the process for taking the

project forward and (3) the criteria by which will review and consider different options

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for the delivery of services (the evaluation criteria). Part of Paul’s role is to make sure

that feedback from this group is taken into account.

Mark Easton then explained how the decision-making process will work.

There will be a two stage process:

Any proposal has to pass certain tests- these are called hurdle (pass/fail)

criteria.

There is then a second stage used to assess the relative merits of the

different options to arrive at scores for the proposals.

The group were then invited to share their thoughts on the criteria through a

facilitated table discussion. Compiled notes from the discussion are below:

4.3.1 Hurdle criteria. Are these the right ones? Have we left any out?

Please see appendix 2 for a full breakdown of the hurdle criteria

General points about hurdle criteria:

Criteria should be written in plain English with examples to explain definitions.

How can we be confident in the application of these criteria – could we set out the

types of evidence that will be used for assessment?

Need clarity on the pathway – where does it start and when does it finish – i.e.

does it include convalescence / rehabilitation. The model of care needs to be

defined or explained more clearly.

Some of the wording is difficult to understand and has the potential for confusion

– e.g. ‘deliver the capacity requirements’ – what does that cover?

How will judgements be made – what evidence will be used? Can we be

confident in the decisions?

Specific comments on the hurdle criteria

No. Hurdle criteria Comment/feedback

1 Emergency departments can

continue to be delivered from the

current locations in SEL

Trauma continuing to be provided

in Trusts that currently do so

Located in SE London

Need to make sure that any work to

change planned care services

doesn’t have a detrimental effect on

other services.

The standard of services (including

trauma) must be maintained or

improved.

2 It meets the clinical requirements set

out in the model

No specific comments. Agreed.

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3 We have options in inner and outer

SEL to be accessible to SEL patients

Participants agreed that access is

very important for patients, families,

carers and staff. If complex care is

only offered from one site then it

could impact on patients with learning

disabilities disproportionately, as they

usually need to spend more time in

hospital than others.

It was felt that ‘Inner’ and ‘outer’ need

further defining or removing. It could

be simplified to: “We have options

accessible to everyone in south east

London”

4a The option makes a positive financial

contribution

Participants questioned whether this

is a good time to do this financially?

The schedule for the programme

looks challenging – this will take time

– no financial benefit until after the

planning period 2020/21.Overall it

was felt that the emphasis should be

on financial sustainability – rather

than making a positive contribution.

4b The proposed option is consistent

with the principle of being open to

all/no winners and losers financially

It should be made more explicit that

this is reference to NHS providers.

5 The option is able to deliver the

capacity requirements

Overall, there was a general

consensus on this criterion.

Suggested additional hurdle criteria made by Planned Care Reference Group

“Must be able to demonstrate effective relationships with social care”

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4.3.2 Second stage criteria. Are these the right ones? Have we left any out?

Please see appendix 3 for a full breakdown of the second stage criteria

General points about second stage criteria

- Should avoid the ‘least effort for the most reward’ approach

- It’s important that the model/work is not contracted out to a private provider

Second stage criteria Comment/feedback

Travel and access Should be reworded “Impact on travel times, taking into

account the needs of the individual”

Deliverability

Add a sub criterion around ‘communication between

providers and professionals including IT & need for

teamwork and integrated working’

Quality Criteria should include access to critical care

Patient experience - Should be broadened to include carer experience

- Does the proposed analysis allow for adequate

assessment of this criterion?

- Include a reference to ‘patient choice’

Research and

education

Should allow for the effective training of health care

professionals in elective and trauma

Workforce No specific amendments – but noted that everyone wants

to have good doctors and staff.

Affordability A strong message that came through was that affordability

cannot trump quality. It was noted that judgement between

clinical and financial criteria is challenging.

There were a number of specific questions raised during the table discussions. Of

note:

Q: We’re concerned about the costs at this point – will NHS really fund it?

A: It was explained that we are not proposing creating a new hospital that we’d aim

to adapt existing sites rather than build a new one, providers are offering proposals

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for how they might accommodate these services on their sites – we are waiting for

these.

Q: How much do cancellations cost?

A: Costs are approximately £1,500 p/day plus cost of theatres – a surgeon offered a

figure of £65 p/min.

4.3.3 Can you prioritise the second stage criteria – high, medium and low

Participants were not able to prioritise the criteria and overall it was felt that all

criteria are important. However, the majority of people agreed that patient

experience, deliverability and quality were considered most significant.

5. Next steps

There was recognition that this was an important project and the work should

continue. The consensus was that these ideas should go forward to options

appraisal and there was no disagreement over the principles of the draft evaluation

criteria. Some elements should be explored in more depth and discussion points

taken into account.

It was agreed that today’s work will be taken to the Committee in Common for

consideration and feed into programme development at its first meeting (17th March

2016).

A full report will be written, following this meeting, and circulated to all attendees and

invitees as well as being published on the website

Lastly, it was agreed that we would hold a third meeting in June (before the second

meeting of the Committee in Common on the 16th June 2016), to look at possible

consultation materials and process (if consultation is agreed).

The Chair thanked the reference group members for attending the second meeting

and the presenters from SWLEOC, King’s College Hospital and Guy’s and St

Thomas’ Hospital, the Chair of the CCGs’ Committee in Common and all those from

the OHSEL programme who had arranged, facilitated and noted the event and the

associated discussions.

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Appendix 1 – Attendees

List of all attendees:

Name Organisation

Annie Gardner Bexley CCG

David Barnett Advocacy For All

Eileen Smith Keep our NHS Public

Ian Fair Member of the Patient and Public Advisory Group

John King Member of the Patient and Public Advisory Group

Katy Wright South East London Vision

Kaz Obuka Lewisham Clinical Commissioning Group

Lesley Wickens Lambeth Mencap

Leslie Marks Healthwatch Bromley and Lewisham

Nicola Rigby Healthwatch Bexley

Olivia O' Sullivan Save Lewisham Hospital

Pat O'Shea Bromley Mencap

Paul Brown Member of the Patient and Public Advisory Group

Paul Richardson Keep our NHS Public

Rob Danavell Southwark Carers

Rosemary Akaighe Advocacy For All

Sharon Hegarty Lewisham Nexus

Stephanie Wood Healthwatch Bromley and Lewisham

Steve Davies Bexley Mencap

Sue Elsegood Greenwich Association of Disabled People and South East London Disabled People's Direct Action Network

Wendy Horler Keep Our NHS public

In attendance from the Our Healthier South East London (OHSEL) programme:

Sarah Blow, Chief Officer Bexley CCG and Planned Care SRO

Mark Easton, Programme Director, OHSEL

Tom Henderson, Programme Manager

Dan Moore, Programme Team

Rory Hegarty, Director of Communications and Engagement

Oliver Lake, Partner - Transformation, Communications and Engagement Team

Jill Mulelly, Communications and Engagement team

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Sam Ridge, Communications and Engagement team

Molly Baack, Communications and Engagement team

Lucy Ing, Communications and Engagement team

Independent chair

Peter Gluckman

External speakers/contributors

Patrick Li (Consultant Orthopaedic Surgeon – Kings College Hospital NHS

Foundation Trust)

Peter Earnshaw (Consultant Orthopaedic Surgeon Guy’s and St Thomas’ Hospital

NHS Foundation Trust)

Steve Thomas, Director of South West London Elective Orthopaedic Centre

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Appendix 2 – Draft hurdle criteria

The tests:

1 • Emergency departments can continue to be delivered from the current locations in SEL

• Trauma continuing to be provided in Trusts that currently do so

• Located in SE London

Pass/fail

2 It meets the clinical requirements set out in the model Pass/fail

3 We have options in inner and outer SEL to be accessible to SEL patients Pass/fail

4a The option makes a positive financial contribution Pass/fail

4b The proposed option is consistent with the principle of being open to all/ no winners and losers financially

Pass/fail

5 The option is able to deliver the capacity requirements Pass/fail

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Appendix 3 – Draft second stage criteria

Description Analysis Weight

Section 2 – Non-Financial assessment 1 Travel and access

Impact on transport times Travel time analysis (for patients by car and public transport including average travel times by mode of transport, and proximity to public transport)

2 Deliverability The option is sufficiently flexible to meet the requirements of growth or changes in future demand or change in national policy. Ease of implementation: the option can be delivered within a reasonable timescale with minimal risk around transition including impacts and disruption to existing services. Capacity and capability: The option demonstrates the appropriate capacity and capability to deliver the change/transition Where investment is required, the ease of obtaining required funding or financing is considered.

Points scored for flexibility to increases/ decreases in demand Estimate of number of years for implementation Estimate of transition risk Assessment of financing/funding options

3 Quality The operating model provides evidence on how it will optimise outcomes for patients

Quality impact assessment (e.g. governance and quality systems) Comparison of current clinical quality of sites which are expected to deliver future inpatient activity under each option

4 Patient experience The option allows the NHS in SEL to comply with the NHS equality duty The model demonstrates how it will optimise patient experience

Equality impact assessment Friends and family and CQC inpatient survey performance against national benchmark

5 Research and education The model provides support the further development of research and education activity

Assessment of impact on research and education

6 Workforce The option is staffable and is attractive to health care professionals working in SEL

Estimate of future vs actual workforce Estimate of impact on current job roles

Section 3 – Financial criteria 7 Affordability - The cost (e.g. capital and transition) of implementing the option represents good value and

is affordable for the organisations impacted. An option will need to have a positive Net Present Value (NPV) to progress.

Capex investment Productivity projections Revenue and cost projections

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Organisational sustainability - The option maintains or improves all organisational positions. Any option which could destabilise the ongoing financial and organisational viability of the individual organisations without a compensating strategy will be ruled out.

Impact analysis on trust current vs future revenue and cost

Pass/ Fail

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Appendix 4 – Participants’ evaluation of the meeting

How much do you agree with the following statements?

Strongly disagree

Disagree Agree Strongly agree

1. There was enough time to discuss the issues

76% (13) 24% (4)

2. I felt able to express my own opinions

6% (1) 72% (13) 22% (4)

3. I feel my views have been listened to

12% (2) 76% (13) 12% (2)

4. I understand why the meeting took place

83% (15) 17% (3)

5. Any other comments?

Too much to manage within the time allowed.

Need more time for questions and discussion.

Being able to see SWLEOC useful example but proof of concept from other

areas around the UK should be sought to help inform models.

Representatives from social care commissioning should be invited to

discussions.

SWLEOC and how that model was run an important lesson not to be lost.

Learn from them as similar enough. Important not to lose the issues of

social care implications after the person leaves hospital.

More emphasis to be shown regarding links with social care and discharge

packages.

The meeting was conducted in an open way; there was not quite enough

time for questions and discussion. Input was interesting from SWLEOC.

The need for patient engagement is crucial but when asked to weight

evaluation criteria, patient experience will always trump deliverability and

finance! Might lead to a biased result…

PowerPoint presentations and packs could use simpler words for people

with learning disabilities and non NHS professionals like myself. A glossary

of abbreviations and jargon would be helpful too.

Will it make any difference when the NHS budget is being reduced,

bursaries are disappearing. The main issue is percentage of G.D.P – now

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less than ever. Also the decision makers in parliament via Simon Stevens

have their hands in the private sector. Far too much money in

commissioning outside management consultants. The specific “elective

unit” ideas are probably ok.

Still have to consider the proposals to give a decision on whether this is

beneficial or not. Impact to be carefully looked at by all stakeholders. It

must not be financially driven.

Some important areas got left out of the discussion…areas that concern my

work and people I represent didn’t have time to be expressed during table

discussions. This was around patient experience. Presentations were very

useful. Needs to be more time for questions/ answers.

I am anxious that these worthy plans are likely to be undermined by the

crises of staffing and funding currently swamping the NHS.