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STRICTLY EMBARGOED 00:01HRS

FRIDAY 24 OCTOBER

DRAFT DOCUMENT FOR

DISCUSSION AND ENGAGEMENT

Clinical options appraisal and

potential way forward

October 2014

Please note that everything detailed within this document is draft and has

been developed with senior clinical staff in North Cumbria University Hospitals

NHS Trust. Further, and more detailed, engagement is required with both

clinical staff, partners and the public. The findings of which will help us to

refine our plans which will then inform discussion with NHS Cumbria Clinical

Commissioning Group.

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Contents Page

Executive Summary 3 Purpose 8 Context 8 Approach - Whole System Working 9

Journey of improvement to date 10 Operational Challenges & Sustainability Issues 12

Sustainable Medical Workforce 12 Medical Workforce Considerations 12 NCUH Priority Issues 13

Clinical Dependencies and Site Determination 17 Service Strategic Direction & Clinical Principles 17

Options appraisal 19 Conclusions and next steps 20 Appendix one – clinical options appraisal 21

Unscheduled care at West Cumberland Hospital 21 Obstetrics and midwifery: Intrapartum care including neonatology 34 Paediatrics 40

Elective care 46 Transport 48 Clinical and System Outcome Measures 50

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Executive Summary

North Cumbria University Hospitals NHS Trust (NCUH) and the health economy it

operates in are under significant pressure with Cumbria identified as one of 11

“distressed health economies” and the Trust is currently in ‘Special Measures’.

Whilst significant improvements have been made, the Trust remains in a fragile

position with some quality standards, operational standards and performance control

yet to be achieved. Services at both sites, but particularly at the West Cumberland

Hospital (WCH), fall short of the incoming seven day national standards, something

the Trust cannot ignore.

Small teams and low activity volumes compound the difficulties of two-site working

and directly impacts on clinical teams’ ability to maintain skills and on training

experiences for junior staff. This also impacts on the quality governance

arrangements and achievement of regulatory and emerging college standards.

These problems, alongside geographical and more recent reputational issues have

directly impacted on recruitment and have led to major difficulties in retaining and

recruiting staff, with local exacerbation of the national shortfall in general internal

medicine (GIM) accredited trainees, and resultant reliance on locums. Some 28% of

Trust consultant posts are currently covered by locums. As a result some services

are operationally extremely fragile; this is particularly true of acute medicine at WCH.

This has been highlighted by the Chief Inspector of Hospitals as of major concern

and importantly, identified as unsafe. Whilst there are clearly further financial

efficiencies to be made, a significant proportion of the current deficit reflects the

structural issues of distant 2-site working.

The Trust does not have any choice when it comes to urgently addressing its

regulatory compliance shortfalls, workforce challenges, inefficiencies and structural

issues in a way that is consistent with the strategy of the wider health and care

economy. It is imperative that these issues are addressed to secure the long term

clinical and financial future.

The Clinical Commissioning Group (GGG) North Cumbria Strategy 2014 – 2019

“Together for a Healthier Future” (TfHF) sets out common principles including right

care, at the right time, and in the right place. The outline proposals for hospital

services within TfHF have been further developed to create an ‘in-hospital’ clinical

strategy for North Cumbria and NCUH which envisages:-

1. An increase in the provision of specialist and high-risk emergency services at the Cumberland Infirmary Carlisle (CIC), consistent with the NHS Services, 7 days a week forum – clinical standards.

2. An increase in the number of people receiving services at WCH. 3. A wider use of clinical networks cross-site and with partner providers to

optimise the use of the limited amount of medical staffing resources.

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The aim is to ensure, at all times, that patients can access the right services at the

right place and time. These services will be clinically safe and will save patient lives.

This may mean that a minority of patients may need to access services in either

Carlisle or Newcastle depending on their clinical needs, but will also mean that more

patients will access the care they need locally. This will allow systematic

standardisation of high quality care across the Trust and further quality

improvements to be made. It is without a doubt that some temporary

transformational changes to acute medical and surgical services have reduced

mortality rates.

Clinical staff involved in developing this draft have, to date, looked at a range of

potential options for change. These have been developed specifically to address the

challenges faced, and ensure the Trust meets all regulatory and other quality

standards. Options have been assessed and initially ranked against criteria that

include their ability to:

deliver safe pathways for patient care

meet all required quality and other regulatory standards

be practicably and sustainably implemented in workforce terms.

Given the significant financial deficit facing the Trust the impact on this is also noted,

although is not the priority issue. There are clearly other factors key to ensuring the

delivery of safe, high quality patient-centred services, these criteria are considered to

be of over-riding importance, and their successful delivery is a fundamental

necessity for the Trust to appropriately manage identified risk.

The Trust has initially assessed the potential options it believes are possible at this

early stage and based on the current evidence available. The Trust’s preferred

potential way forward is detailed in summary below as well as other core service

elements:

Maximisation of the opportunities offered by the new WCH redevelopment to

create a centre for excellence for lower risk care in West Cumbria, fully

integrated with community provision and with delivery of higher risk and more

specialised care at CIC and beyond (where appropriate i.e. Newcastle)

Inpatient & ambulatory/outpatient elective and speciality shift to WCH and

where appropriate, community hospitals, considerably increasing the total

volume of care that can be delivered locally to patients across all of North

Cumbria

Continuation long-term of the arrangements made on safety grounds in 2013

for transfer of high risk trauma and surgical patients to CIC, based on clear

evidence of improved clinical outcomes and reduced mortality rates

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Transfer of designated high risk unscheduled medical pathways (as well as

above surgical pathways) from WCH to CIC, with detailed pathway

development and planning as soon as possible to enable better clinical

outcomes

With regards to maternity services, although the Trust has discussed

potential future solutions, particularly to help address critical safety

issues with regard to anaesthetic cover, no preferred option is stated

and all potential solutions are fully dependent on the outcome of the

independent maternity review which has been commissioned by NHS

Cumbria CCG.

A 24 hour Short Stay Paediatric Assessment Unit at WCH, supported by 24

hour paediatrician access, low acuity beds and a full In-patient Unit at CIC

working as part of a system-wide child health network

Please note the above preferred potential way forward is based on current

thinking and has been pulled together with senior clinical engagement,

although it still requires more comprehensive clinical and stakeholder

engagement and therefore may change over the coming months.

It is also noted that the planned Independent Review of Maternity services by

NHS Cumbria CCG, which must also closely examine issues concerning

anaesthetics, is yet to take place and more detailed modelling and analysis

would be required on all options. The Trust remains open-minded to

alternatives which can demonstrate that they better meet current challenges

(particularly in relation to anaesthetics). System leaders will wish to review

potential options in light of the Independent Maternity Review and further

detailed modelling and options appraisal is required.

The Trust’s preferred way forward in other areas seeks not only to secure

sustainable services for the long-term but also to maximise local service availability

wherever possible. The opening of the new West Cumberland Hospital in 2015

provides the ideal opportunity for newly configured services to be implemented.

The availability of appropriate transport to support preferred options presents a key

challenge to implementation: it is recommended that the CCG be requested to

commission an inter-hospital transport solution to support local communities and

address any concerns raised relating to the transport between Cumberland Infirmary

and West Cumberland Hospital.

The preferred way forward is expected to enhance clinical outcomes, not just on one

site but across the Trust as a whole through ensuring a sustainable model that

facilitates service development and quality improvements in the long term.

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This draft clinical strategy, coupled with a comprehensive and innovative approach to

recruitment, allowing substantive net recruitment of 1 consultant & 1 specialty doctor

post every 3 months, anticipates the ability to secure a significantly more permanent

consultant workforce in 3 years as well as becoming a ‘trainer of choice’ for Health

Education North East (HENE), with increased fill rate and allocation of training

posts1. This strategy does not as yet take into account medical productivity changes

with the diagram below demonstrating the minimum expectation of shifts in

substantive posts as a proportion of the total establishment:

Ultimately the Chief Inspector of Hospitals will give final opinion on whether service

and workforce proposals can secure a safe and sustainable workforce, and will need

to have confidence in the Trust’s best judgment in relation to timescales for change,

and success in reducing risk through reduction in temporary staffing through our

workforce strategy.

This paper describes a clear strategic direction and provides credible and

transformational potential options which are implementable for the delivery of

1 Note: Whilst a simplification and not strictly accurate use of terminology, in this context and

throughout the document the term ‘Specialty Doctors’ is used to denote Specialty Trainees: ST Higher

(ST3 plus), ST3+ equivalent including SAS doctors; ‘Trainees’ denotes Lower Trainees, CMTs, F2s,

GPVTS, and ST(Lower).

Percentage Substantive Posts Against Establishment

As at September 2014 Post Change: April 2017

79%

72%

62%

52%

x%??

66%

Consultants

Middle Grade

Junior

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safe, high quality and regulatory-compliant secondary care in North Cumbria.

Potential options are based on best available evidence to date and have been

designed to most successfully mitigate the significant risks within the existing

system, and to ensure that safe, service provision can be built upon and

sustained longer term.

Significant further cross-system work is needed to define out of hospital

initiatives and the anticipated impact on the Trust both in terms of new ways of

working and in expected reduced in-patient activity. This may require revision

of the current thinking which is based on existing activity levels.

The Trust remains open-minded to consideration of alternatives which can

demonstrate they better meet the current challenges. Additional Trust Board

consideration and on-going development of this high level strategy will be

required in conjunction with clinical teams, partners, regulators, and other

stakeholders over coming months. Robust governance arrangements will be

agreed internally and with external partners to further progress the work.

However and, to be clear, this document focuses on what the Trust, to date,

believes could be the potential way forward based on the evidence available.

The next steps are to engage further regarding these initially assessed and

ranked potential options, the outcomes of which will inform further

conversations with commissioners who will ultimately determine the services

commissioned within the local communities following a comprehensive

programme of engagement and public consultation.

Ann Farrar, Chief Executive

October 2014

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Purpose

This paper sets out to date, the potential way forward for secondary care. It describes

the challenges in delivering this care, considering those core services faced with

critical issues, and explores options to make them clinically sustainable in the long

term. Consideration of specialist provision is beyond the remit of this paper and will be

taken forward through a separate mechanism. However, the common aim is to

maintain these services locally, ensuring they are delivered in accordance with NICE

guidance using systematic service reviews to consider the capacity requirements,

sustainable workforce solutions and best operating model for future service delivery.

Work has already started with radiotherapy and vascular services, with remaining

specialised services to follow.

The potential options detailed within this document confirm, to date, the Trust’s clinical

thinking relating to how it can practically meet both short and long term operational

and quality service requirements.

The Chief Inspector of Hospitals will re-visit the Trust shortly, and will review the

progress made to formulate a robust long term strategy which addresses the

sustainability issues in relation to medical workforce, particularly in acute medicine at

West Cumberland Hospital (WCH), and which has a clear and realistic plan for its

delivery. This will determine if sufficient improvement has been made, to remove the

“inadequate” rating for acute medicine at WCH and ultimately allow the Trust’s

removal from Special Measures.

This draft paper has been developed to support further discussion with staff

commissioners, partner providers and other stakeholders. Whilst options have been

identified, the Trust is open-minded to alternatives which can demonstrate that they

better meet current challenges, and will continue to work closely with its doctors and

nurses, the public, stakeholders and others to develop the very best possible

solutions.

Context

North Cumbria University Hospitals NHS Trust (NCUH) is the secondary care provider

in North Cumbria providing services to 340,000 people predominantly from its two

sites, the Cumberland Infirmary at Carlisle (CIC), and the West Cumberland Hospital

(WCH) in Whitehaven. The Trust also provides a midwifery-led service at Penrith

Birthing Centre.

The Trust, and the health economy it operates in, are under significant pressure, with

Cumbria identified as one of 11 “distressed health economies”. The Trust is in “Special

Measures”, by virtue of it currently failing to achieve on some aspects of quality

standards, operational performance and financial control. Services at both sites, but

particularly WCH, fall short of the incoming 7 day national standards.

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The geographical distribution of the population and two site working is challenging:

whilst as individual factors they are not unique, it is highly unusual to combine these

with the distance between the two sites, (and between the smaller site and the tertiary

centre) as well as the volume of activity at the smaller site, which serves a significant

and overall disadvantaged urban population. Current secondary care service

provision, with two hospitals receiving unselected “blue light” admissions, results in

duplication of emergency services across low volume sites; of only six medically led

obstetric units in England with less than 2,000 deliveries per year, two are within the

Trust. These characteristics combine to create major operational and workforce

challenges.

NCUH was visited in April 2014 by the Chief Inspectors of Hospital’s Team, receiving

an overall rating of “requires improvement”. Whilst all services received a “good” rating

for delivery of ‘caring’ services, two areas were rated as “inadequate” under the safety

domain: acute medicine at WCH and outpatients at both sites. Of major concern was

the operational fragility of the medical workforce and the lack of a long term strategy to

address this.

Events of the past 12 to 24 months including the Keogh Review and Chief Inspector’s

visit, the withdrawal of some junior doctors from WCH and ongoing recruitment issues

have combined to create a burning platform for transformational change in secondary

care services: it is now imperative that this is agreed and delivered at pace, and is

supported by the entire health and care system in North Cumbria and beyond.

Approach - Whole System Working

Whilst the long-term viability of some core secondary and local specialist services

have been highlighted as of concerns for many years, and there have been multiple

plans to reform health service provision for Cumbria, to date, these have failed to

address the underlying issues. More recently, with other partners in Cumbria

experiencing challenges, and recognising the interdependencies and common

themes, health and social care clinical and managerial leaders have committed to

work together to find shared solutions as a system-wide Cumbria Health & Care

Alliance.

The North Cumbria Programme Board (NCPB) was established in February 2014 to

develop and implement a joint strategy for North Cumbria health and social care which

would ensure clinically and financially sustainable high-quality services. Under the

banner “Together for a Healthier Future” (TfHF).

Clinically-led Care Design Groups considered options based on principles of “right

care, at the right time, and in the right place” which would:

radically increase the scale and integration of out of hospital services based

around primary care communities,

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achieve sustainable high quality provision by delivering a programme of

hospital services consolidation, and

enable a modern model of integrated services and delivery of the Cumbria well-

being strategy.

The concepts of integration and consolidation are critical and wholly interdependent.

Their successful delivery is reliant on the success of joint working across the health

and social care environment. The ‘North Cumbria Strategy 2014 – 2019’ sets out

scenarios for hospital service configuration created across a continuum, which have

been used as the basis for initial modelling and analysis of TfHF service options which

are set out in the following sections. Work in parallel is considering the detail for ‘out of

hospital’ provision.

Journey of improvement to date

Since arriving in September 2012, the leadership team at North Cumbria have always

been very clear that the organisation is on a long journey of improvement which will

require continuing stability to move from being a failing trust, over many years, to a

high performing successful NHS trust.

Despite the on-going configuration and recruitment issues, significant improvements

have been made and there are now some very clear milestones in the Trust’s

improvement journey over past 18 months which should be recognised. Most notably,

is the reduction in the Trust’s mortality rate which was one of the highest in England

two years ago and is now within expected limits and has continued to decline on a

quarterly basis over the past year.

This is thanks to very difficult but vital changes made to improve patient safety and the

Trust now has very clear evidence that less people are dying in the Cumberland

Infirmary and West Cumberland Hospital, with more people surviving serious injury or

illness and going on to live longer lives with better outcomes following their stay in

hospital. It should be noted however, that WCH has historically had higher mortality

rates than the Cumberland Infirmary (CIC) and this continues to be the case (although

both are now within expected range).

In addition, staff should be rightly proud of the fantastic achievement of a ‘good’ caring

rating for all services and departments from the Chief Inspectors of Hospital’s visit in

July 2014

Throughout their visit, the CQC witnessed patients being treated with compassion,

dignity and respect at all times with staff clearly very committed to achieving the very

best for their patients. The Trust is immensely proud of the tireless efforts of each and

every member of staff who regularly go beyond the call of duty, in very challenging

circumstances, to provide compassionate care.

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These positive changes in mortality and quality of care have not happened by

magic. They are the result of some specific service changes made on safety grounds

during 2013 and the momentous efforts by all staff who continue to put their patients

first and respond fantastically well embracing the challenges faced on a daily basis.

Despite these significant improvements, the Trust is extremely aware that the way

some services are currently delivered is still not as good as it should be, or to the

standards expected of the professional bodies and Royal Colleges of nurses,

midwives and doctors.

It is important to note that the CQC, following their latest inspection in April 2014, also

rated the safety element of care at West Cumberland Hospital as inadequate as a

result of the unstable position with regard to acute medical staffing.

The CQC also recognised that for North Cumbria in particular, the complex and

geographically challenged environment adds further difficulties in solving some of the

challenges faced, particularly around recruitment.

Although there have been previous attempts, as part of the ‘Care Closer to Home’

consultation in 2008, to address some of these issues by moving more care outside of

hospital, into the community and peoples’ homes, and to consolidate certain specialist

hospital based care – the hospital elements of these plans were ever brought to

fruition under previous system leaders.

The problems in North Cumbria have therefore never been solved or been allowed to

be truly addressed.

Whilst these problems are without doubt difficult, they are not impossible to solve,

however they have already, and will continue, to require change and challenge of the

status quo in order to provide the very best care for patients.

Work over the summer with the Trust’s senior clinical teams and in partnership with

NHS Cumbria CCG as part of the NCPB, has now started the conversation about the

potential way forward to address the challenges which remain.

To be clear, the Trust’s ambition for North Cumbria is to make hospitals in Carlisle and

Whitehaven as good as the best in the NHS and deliver the highest possible

standards of clinical care that each and every one of us would expect for our own

loved ones.

Change, by its very nature, is never easy but in order to deliver this ambition of high

quality, person centred healthcare, the challenges we face must be tackled once and

for all. This will require joint working with all health and social care partners to develop

pathways of care that will mean the best possible outcomes for each and every

patient.

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Operational Challenges & Sustainability Issues

The following details further the operational and sustainability challenges the Trust is

facing now and into the future. The potential options assessment and ranking

considers these challenges. Our focus will always be to ensure the Trust delivers high

quality services without compromising on safe care. To do this, we must all recognise

the challenges staff are tackling day in day out.

Sustainable Medical Workforce

The issues facing the Trust are well rehearsed and commonly understood. As

previously outlined, running two isolated District General Hospital (DGH) sites

geographically distant from each other and from tertiary/specialist support, has

resulted in clinically unsustainable working practices and major difficulties in sustaining

medical staffing rotas. Small teams and low activity volumes have further compounded

difficulties, impacting on: skills maintenance; training experience for junior staff; quality

governance arrangements and achievement of regulatory and emerging college

standards. In addition, this is also financially unstable.

These problems directly impact on recruitment and have led to major difficulties in

retaining and recruiting staff, with a subsequent over reliance on locums which is

unsustainable in the long term. As a result, some services are operationally extremely

fragile; this is particularly true of acute medicine at WCH. Out of a total of 203

consultant posts Trustwide, 46 are currently covered by locums/agency staff; for

middle grades this is 66 out of 127 posts.

Medical Workforce Considerations

Current nationally agreed consultant contract on-call requirements mean that is highly

inefficient to run with an emergency/7-day rota of less than 5 consultants. More

importantly, in practical terms recruitment is, and will become increasingly, difficult with

fewer than 8 consultants in a rota. Seven day working requirements and other specific

Royal College requirements (for example, dedicated intensivists, 24/7 A&E Advanced

Trauma Life Support (trained medical staff presence), add significantly to the

challenge, although national contract changes may in part alleviate this

In addition, consultants increasingly wish (and should be encouraged) to sub-

specialise to enable improved outcomes for patients, with a range of skills provided

across a team (note in this instance services such as general surgery, gynaecology,

orthopaedics). Maintaining multiple sites with low levels of activity restricts this skills

development and maintenance, increases professional isolation and impacts on job

satisfaction. Whilst the Trust could seek to develop ‘buddying’ arrangements to

address this in part, it will not fully compensate and is likely to be an expensive model.

These issues, as well as impacting on quality and consultant productivity, have

significant impact both on the ability to train doctors and ultimately the attractiveness

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of posts and ability to recruit and retain consultants, particularly in consultant

specialties where there are national shortages. As a consequence, whilst safety of

services has been maintained, they are not necessarily resilient, with over-reliance on

a few individuals and an ageing workforce, and where potentially a single resignation

may destabilise an already fragile service.

Significant use of locums is not an acceptable long-term solution either financially or

more importantly in terms of quality, continuity and service development. Differences

in mortality between sites are likely to be directly associated with the severe consultant

workforce difficulties at WCH. Services are also vulnerable due to short notice

contracts.

Resident specialty doctor recruitment is challenged by similar issues, with onerous on-

call requirements, inability to develop speciality skills and professional isolation.

Medical workforce problems are compounded by the system-wide lack of qualified and

unqualified nurses, with difficulties in recruitment across all providers; the Trust

remains reliant on a combination of additional hours, bank and agency nursing and the

sheer goodwill of staff, to maintain safe nursing levels in line with the Francis

recommendations.

Finally, an ability to recruit and retain sufficient specialist staff to retain training doctors

has had an impact on the allocation of trainees by HENE speak at and problems

recruiting to NCUH rotations. As a result of locum usage and subsequent inability to

provide an appropriate training experience, there will be no trainee doctors at WCH

from 2015, excepting those on the GP Vocational Training Scheme.

HENE colleagues confirm that due to national workforce issues, despite the significant

efforts made by the Trust, supported by buddy trust and acquisition partner

Northumbria Healthcare NHS Foundation Trust (NHFT) including dual appointments

and NHFT secondments, the situation is unlikely to significantly alter.

A reduction in the proportion of locum usage to acceptable levels will require not only

innovative and sustained approaches to recruitment and retention, but also

rationalisation of overall consultant numbers achieved through implementation of

integrated competency-based and multidisciplinary models of care which are

sustainable in the long term and are, ultimately, more likely to attract more candidates.

NCUH Priority Issues

Whilst the challenges above are relevant to all of The Trust’s services, three specific

high-risk issues must be resolved by the Trust as a matter of urgency ensuring an

appropriate balance of safety issues and patient-centred access at all times:

a. WCH Unscheduled Care

The Trust has struggled to recruit to consultant and middle grade medicine

posts over several years. As at September 2014, there were cross-Trust

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vacancies in 21.5 out of 35 Acute Medicine & Care of the Elderly consultant

posts; five out of seven consultant on call positions are filled by locums at WCH

and four out of ten at CIC. Amongst resident medical doctors, vacancies are 15

out of 36 and all WCH posts are filled by locums. Vacancies in specialist posts

are significant cross-Trust, particularly for gastroenterology, respiratory, care of

the elderly and general cardiology; Acute Care Physician (ACP) cover is largely

dependent on secondees from Northumbria Healthcare. In A&E there is circa

50% reliance on locum consultant cover.

This over-reliance on locums in acute medicine at WCH has severely impacted

on the Trust’s ability to provide an appropriately supervised high quality

educational experience at WCH and junior trainees have been consequently

withdrawn. Unfilled middle grade posts from August 2014 put in jeopardy the

Trusts’ ability to maintain acute medicine in its current form, but following

strenuous efforts, the Trust successfully appointed locums to all nine posts

maintaining safe service provision in the short term. Additional rota and surgical

support changes have been implemented from August 2014, including the

planned use of nurse practitioners both day and night. The Trust and wider

system have developed robust contingency plans to manage potential rota

collapse in acute medicine including those for a ‘worst case scenario’, with

changes to emergency flows in West Cumbria and use of CIC overnight.

This, however, is an untenable position longer-term and a service configuration

which can be delivered by a largely substantive workforce is essential.

b. Obstetrics and Gynaecology

Current arrangements are the provision of the 2 site obstetrics, including

anaesthetic and paediatric cover and neonatology, as well as the Penrith

Birthing Centre. Neither district general hospital site operates a Midwifery Lead

Unit (MLU), nor does CIC currently offer an epidural service. Whilst the

maternity dashboard demonstrates an acceptable position in many (but not all)

areas, and CNST Level 1 achievement, arrangements are not compliant with all

current regulatory requirements. Specific regulatory, NICE, CNST2 and College

Guideline2 compliance issues that must be addressed include:

Lack of dedicated resident anaesthetic support across both sites

resulting in risks associated from management of multiple workstreams,

2Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists’ Association OAA /AAGBI

Guidelines for Obstetric Anaesthetic Services, 2013 Clinical Negligence Scheme for Trusts, Maternity Clinical Risk Management Standards 2012/13, January 2012

RCOG, RCM, RCA& RCPCH. Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in

Labour, October 2007

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in addition to insufficient dedicated daytime anaesthesia service at WCH

and lack of epidural service as a key option for pain relief at CIC

Lack of dedicated theatre team with immediately available anaesthetic

and theatre staff for emergencies at WCH

Lack of dedicated second theatre and theatre staff for caesarean

sections beyond two (WCH)/three (CIC) elective caesarean sections

(LSCS) lists per week

The critical issue, however, for obstetrics relates to the availability of

anaesthetic/intensivist support. Anaesthesia at WCH has not been able to

develop separate streams of anaesthetic cover for maternity and intensive care.

Units that rely on a shared anaesthesia/ITU on call generally have developed

separate 7/7 staffing for ITU and maternity, have greater resilience in total

anaesthetic numbers and have a busier caseload for other anaesthetic streams

of work to attract staff. The combined workstreams have been noted as factors

within recent anaesthetic (non obstetric) ‘never events’.

Even with existing sub-standard anaesthetic/ITU staffing levels, there are

numerous vacancies at both middle grade and consultant levels; WCH currently

has no anaesthetic trainees. Despite the doubling of CCTs in anaesthetics in

2011/12 only one successful appointment was made at WCH during this period.

There is major difficulty in recruiting middle grade obstetric staff at WCH with

the service run by three 12 PA (equivalent of 48hr clinical and non clinical paid

time) specialty doctors, and long-term locums generally used to cover night

duty. At CIC there are difficulties in maintaining the resident medical rota as it is

reliant on speciality trainees - however there is a national shortage: gaps have

had to be filled by locum consultants with resident on-call duties. Resident

anaesthetic trainees have variable levels of experience.

Risk mitigation plans in place include a third anaesthetic on-call rota 24/7 at

WCH to cover for simultaneous emergencies, and written escalation plans

including prioritisation of work guidelines. There is close monitoring of

outcomes through the maternity dashboard and patient experience feedback.

Arrangements are being made to ensure epidural can be provided at CIC as a

choice option to women in labour.

Business cases have been developed for a dedicated theatre team and

obstetric anaesthetist (not utilised in transfers) to replace current arrangements

which require disruption of elective lists. At CIC, where there is only one

resident anaesthetist out of hours covering all areas (obstetrics, theatre, ITU),

proposals include separate ICU consultant cover in addition to the 2 obstetric

consultant anaesthetists covering CEPOD (emergency lists) / obstetrics.

Following NCUH formally raising concerns in relation to service sustainability, it

was concluded that current operational and risk mitigation arrangements for

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maternity were satisfactory, and that long-term configuration issues should be

dealt with as part of the local system planning process. NCPB commissioned

an Independent Review of Maternity service; this has been significantly delayed

to date but is expected to take place in November 2014 led by a past President

and current Deputy President of the Royal College of Obstetricians, with the

outcome made known by December 2014. It is noted that the Chief Inspectors

of Hospitals report also highlighted that maternity services at WCH were ‘not

sufficiently safe’ (largely due to medical cover – specifically anaesthetics)

c. Paediatrics

Due to the interrelationship and co-dependencies of paediatrics with intensivist,

A&E and obstetric services, it is vital that consideration is given to paediatric

provision in any discussion of other service changes. Consultant-led obstetric

services require 24/7 resident paediatric presence, as well as paediatric

consultant cover and paediatric services support A&E and in turn require

intensive care support. The interrelationship with community child health

provision is also key.

Present arrangements for both medical and nurse staffing in paediatrics do not

meet current college recommendations or Royal College of Paediatricians and

Child Health required standards34 , and concerns were raised by the Chief

Inspector of Hospitals in relation to the robustness of night-time paediatric

cover.

Currently paediatric and neonatal units at CIC and WCH deliver a traditional

provision for medical and nursing care; there are two consultant led in-patient

units with junior doctor support and some speciality doctor input, with the

exception of the neonatal unit at CIC site where senior nurses with expanded

skills initiate the care of the neonate supported by the Paediatric Consultant.

This area has no junior doctor input. Historically, CIC has tended to run without

recourse to appointing resident paediatric medical staff to cover gaps in trainee

rotas.

Adult high dependency unit (HDU) beds are used at WCH for the management

of critically ill children. HDU support is not explicitly commissioned at NCUH

with additional resource, but there are long-standing custom and practice

arrangements whereby the Trust manages HDU-level requirements. Both sites

successfully manage CPAP (Continuous Positive Airways Pressure) treatment

in children and it is noted that Newcastle Hospitals do not have a retrieval

service for non-ventilated children from the Trust thereby currently offering little

alternative to current practice.

3 Royal College of Paediatrics & Child Health; Facing the Future: Standards for Paediatric Services, April 2011

4 It is noted that consultation on revision to the 2011 standards closed on 15

th September 2014

17

The unattractive 3-tier out of hours arrangements at WCH, with a consultant

sleeping in to support paediatric emergencies, are not sustainable; at CIC

consultants are called in from home. Removal of specialty trainee doctors at

WCH has made recruitment to resident posts problematic, and whilst currently

managing to recruit there are expected to be increasing difficulties in securing

substantive consultant appointments which can meet the increasingly onerous

Royal College requirements. Whilst some investment has been made in

paediatric nurse practitioners (PNPs) which will assist, recruitment and training

of these staff is challenging and further investment needs to be made to deliver

paediatric care with an integrated PNP rota.

Clinical Dependencies and Site Determination

Where a service can only reasonably be safely maintained from one site, a

decision must be taken as to which: by virtue of geography and transport

to/distance from the nearest tertiary centre(s).

Understanding service co-dependencies is essential in determining site

configurations: A&E, intensive care and acute medicine are inter-reliant; to

function as a Trauma Unit as part of the regional trauma network (CIC has

designated trauma unit status) requires A&E, intensive care, general surgery,

trauma and orthopaedics, blood products, lab. and radiology support. Equally,

consultant obstetric provision requires support from anaesthetics, ITU, and

paediatrics (as detailed above) and there are limitations in operating without the

support of the range of other surgical specialties, creating interdependencies for

general surgery, gynaecology, T&O, ortho-geriatric and endoscopy.

Service Strategic Direction & Clinical Principles

As highlighted in Monitor’s April 2014 strategy,5 focus needs to be “on maintaining

services, not institutions”. Our patients do not distinguish between different provider

organisations and neither should we: our primary interest is in ensuring delivery of

seamless high quality and efficient care with our partners, across the health and social

care.

The Trust’s Integrated Business Plan and CCG 5-Year Strategy Together for a

Healthier Future both describe how the key changes we expect to be delivered in

conjunction with our partners, will shape the care experienced by patients and their

families:

5 Monitor strategy 2014 to 2017: Helping to redesign healthcare provision in England, April 2014

18

There will have been a reduction in reliance on in-patient care: more patients

will be treated in community or ambulatory care settings involving NCUH staff

directly supporting patients in their own homes, through support of primary and

community teams, through high quality outpatient and ambulatory care

services, and through integrated approaches to admission avoidance and early

discharge. Our focus will be on supporting patients and their families with the

“right care, at the right time, and in the right place”.

For those patients who do require hospital in-patient care, high quality, safe and

effective care with early senior assessment and rapid access to specialists and

diagnostic tests 7 days a week will be provided, with timely onward referral for

tertiary support where indicated.

Delivery will be through ‘integrated’ teams, both multi-disciplinary and inter-

provider/agency, which work to minimise duplication and maximise continuity

and efficiency of care: our focus will increasingly be on prevention (both primary

and secondary), and included within this as core practice will be patient

involvement in proactive care planning and an emphasis on enabling self-

management.

Delivery of care will not just be technically excellent, but will be caring,

responsive and compassionate, tailored to individual needs and wishes at all

times. This will enhance both patient and staff satisfaction: patients and families

will meet staff who are proud of their work, and who have time to continually

improve their services.

Patients and their families will be confident that where care has not been

delivered to the standards they would wish, this will be readily acknowledged,

fully explained and changes made speedily to rectify problems.

There will be continued delivery of care locally wherever possible, and

‘centrally’ where necessary to achieve best clinical outcomes; in this context

‘centrally’ may be any hospital site, a specific North Cumbria site or beyond: our

principle will be that care will be delivered as locally as it is possible to deliver

high quality, safe care making best use of finite Cumbria resource.

The Trust expectation is of secondary services working as a single entity in delivering

services across North Cumbria, with clinical networks supported by flexible working of

its staff. Wider clinical networks from outside the County will continue to be developed

both with buddy trust Northumbria Healthcare NHS Foundation Trust as acquisition

partner and with tertiary centres and other providers. The Trust principles

underpinning configuration of services are:

1. Safe, effective, patient-focused and compassionate care at all times and in all

places,

2. Compliance with all regulatory and quality standards

3. More patients than currently to receive services local to where they live

4. Specialist skills in WCH-based staff to be maintained and developed

19

5. Increasing provision of “one stop” services

6. Specialty support to in-patient activity at WCH to be secured through outpatient

and elective service providers

7. Specialty provision enabled through visiting consultants (whole days of activity)

and networked specialty services across Trust sites,

8. Access to secondary care services differing dependent on geography, as

happens with tertiary services

9. Clinical networks across the Trust providing the best balance between

centralised specialist care and outreached specialist care

10. Not all specialist services required to be on the ‘centralised site’

11. 24 hour and 7 day services to improve safety, quality and efficiency

Measurement of quality, operational and financial performance in all parts of the Trust

will drive improvement. Agreed performance indicators including compliance with

regulatory standards, college guidelines and local pathways and protocols will be

routinely monitored.

Options appraisal

The initial clinical options appraisal for key service areas has been considered in more

detail in appendix one and has been designed to address specific models of care

where there are clinical sustainability concerns. Options have been designed to

manage these risks and the potential implications and are assessed against criteria

that include their ability to:

deliver safe pathways for patient care,

meet all required quality and other regulatory standards,

be practicably and sustainably implemented in workforce terms.

Given the significant financial deficit facing the Trust the impact on this is also noted,

although is not the priority issue. Whilst there are clearly other factors key to ensuring

delivery of patient-centred services, these criteria are considered to be of over-riding

importance, and their successful delivery is a fundamental necessity for the Trust to

appropriately manage identified risk. Issues of access and patient experience must be

appropriately balanced by those of safety and clinical outcomes.

It should be noted that modelling is based on current activity levels; significant, further

cross-system work, is needed to define out of hospital initiatives and the anticipated

impact on the Trust both in terms of new ways of working and in expected reduced in-

patient activity. This work will continue to be led by the CCG through the NCPB/TfHF

arrangements and Health & Wellbeing Board leadership of the Better Care Fund

plans.

Appendix one shares in greater detail the options appraisal for each of these

areas

20

Conclusion and next steps

In conclusion, the Trust Board is clear of the opinion that to ensure the services it

provides are clinically safe and financially sustainable that change is not an option but

a necessity.

The evidence relating to the challenges articulated within this document continue to be

collated and will be further developed as the Trust progresses to more comprehensive

engagement with clinical staff. The findings of the Independent Maternity Review will

also add to a body of evidence that will support conversations with the local

commissioners of health services.

Over the coming weeks the Trust will engage in detail with clinical teams across the

organisation and with partners and has also commissioned independent public

engagement regarding the potential options detailed within this document.

The findings of this engagement will then be fed into final Trust recommendations

which will then be shared with the clinical commissioning group.

To be clear, this is NOT a consultation document, but a working draft clinical

strategy. This has been designed to support further clinical and public

engagement regarding the potential options detailed within this document.

It is the role of the commissioners of health services in Cumbria (NHS Cumbria CCG),

who are the leaders of the local NHS, to determine, based on the evidence available,

what they believe to be the options for the provision of health services. The final

options which they develop and refine, if there is a material change within a provided

service, will then be engaged and fully consulted on within the local community.

21

Appendix one – Clinical Options Appraisal

Unscheduled Care at West Cumberland Hospital

The hospital operates two distinct areas for medicine: ‘Front of House’ dealing with

acute admissions, and Back of House covering the medical wards for respiratory,

gastroenterology, general medicine and elderly. As from August 2014, night-time

medical cover has been provided by Hospital at Night (H@N) nurse practitioners

supported by resident middle grades, plus a consultant on-call (non-resident).

Non elective surgical care

In line with newly agreed arrangements, the management of non-elective/emergency

surgical assessment includes middle grade surgical presence only between 8am-8pm,

7 days a week. Moderate/high risk emergency surgical referrals are expected to be

made directly to CIC; low risk patients with surgical problems during the day time are

assessed in the ambulatory care unit; at night assessment is provided where possible

via the ambulatory care unit without admission (and return the following day), admitted

to WCH under the medical team if more appropriate, or transferred to CIC. This model

anticipates clinical assessment in A&E and subsequent pathway management without

rigid allocation to traditional medical & surgical ‘specialist’ streams: for example

patients with abdominal pain identified as not in need of surgery can be admitted at

night by the H@N Team pending surgical review in morning. This ensures that the

service provided responds flexibly to the needs of the patients rather than a reliance

on specialty support.

Continuation of these arrangements is assumed unless stated otherwise. It is noted

that some changes were made on safety grounds and will require formal public

consultation; some of the outcomes associated with these moves are evidenced under

‘clinical and system outcome measures’ section.

Proposed Clinical Pathway Changes

The preferred way forward focusses on managing the risks associated with

unscheduled care on the West Cumberland Site given the over-reliance on locums,

the extreme fragility of the medical workforce at WCH, the support that can be

provided to other WCH clinical services, and the currently evident site impact on

patient outcomes (mortality).

Current Model

The current arrangements for WCH takes all emergency admissions - “blue light” and

self-referrals as well as GP admissions, excepting some specific recent service

changes (see below) to manage certain high risk patients presenting in West Cumbria

at CIC:

Major trauma

22

Trauma requiring urgent/immediate operative procedure

Patients suitable for PCI or other CIC Heart Centre intervention

High Risk Emergency Surgery – i.e. requiring urgent/immediate operative

procedure

High risk vascular surgery (Tier 3)

Major GI bleeds out of hours

Patients not recognised by GPs/paramedics at presentation or self-referrals are

assessed, provided with immediate treatment as required and transferred to CIC (or

more distantly) for continuation of their care. Where possible, patients are ‘repatriated’

to WCH as soon as is clinically appropriate and practicable.

Option UC1 – Diversion/Transfer of High Risk Patients to CIC

Clinical Pathway

Option UC1 seeks to ‘de-risk’ the WCH site from its currently fragile state through

transfer or diversion of certain medical patients identified as at high risk, day and night

from WCH to CIC. It is proposed that these patients will benefit from the additional

resources, skills and expertise available on the CIC site, with lower risk patients

continuing to be safely managed at WCH.

Patients who can reasonably be identified in community settings can be immediately

transported to CIC either through discussion with their referring GPs or as a result of

paramedic triage. Those presenting at front of house are assessed, stabilised and if

meeting the criteria transferred to CIC. Patients are repatriated to WCH to complete

their care as soon as clinically appropriate; this includes patients stepped down from

critical care at CIC.

The implication of UC1 is that only selective ‘blue lights’ are taken to WCH, and with

the designation of the unit to be finally determined in line with national 'Urgent and

Emergency Care Review' definitions. This allows implementation of a model of care

delivered from an ‘emergency floor’, a concept previously agreed with commissioners

but not to date fully implemented. Front of house early assessment is provided from an

integrated team consisting of ED consultants, acute physicians, nurse practitioners

and critical care doctors. The whole system is supported by a Back of House team

including Critical Care and critical care outreach. Patients who require ventilation can

be safely managed on-site with over-night care and longer as necessary in advance of

transfer to CIC if clinically appropriate. The model is reliant on genuinely cooperative

working across the out of hours medical workforce working as a single team that sees,

assesses and “clerks” patients (see below).

Speciality support and advice is provided as required at night from CIC; the two sites

work increasingly together as a joint entity by day and night, with an expectation of

routine cross-cover, rotation of staff between sites, and maximisation of specialist

(direct or indirect) support of rotas.

23

Patients admitted to the WCH site will have access to intensivist support and facilities

with critical care/higher acuity beds including increased monitoring, inotrope support

and NIV, plus acute and post-acute care. Admission decisions options are based on

the following clinical pathway possibilities and are driven by the needs and best

interests of the patient:

Anticipated for home within 24 hours,

No specialist intervention is needed and patient is sufficiently stable to be transferred to ‘back of house’ medical ward +/- subsequent transfer to sub-acute ward,

Patient is high risk and would benefit from transferring to CIC for specialist treatment and intervention with repatriation when possible.

Clear admission and transfer criteria will be used with “Standard operating procedure”

for transfers, and with staff competency requirements defined by patient acuity.

Patients to be transferred from WCH front of house are stabilised, and managed until

they can be safely and appropriately transferred.

Proposed criteria for High Risk6:

Patients are identified as at high risk and suitable for CIC transfer on the basis of:

I. initial diagnosis (at front of house or by paramedic staff) of an agreed high risk

medical pathway,

II. High NEWS score.

High risk patients identified as suitable for transfer against the following criteria:

1. Medical admissions with NEWS score greater than or equal to 7 during their ED

admission AND/OR greater than or equal to 5 following appropriate ED

treatment (excluding respiratory failure patients suitable for NIV in WCH ICU).

2. High risk chest pain (determined by chest pain pathway) i.e. Acute Coronary

Syndrome/NSTEMI with NEWS below criteria 1.

3. Stroke (diagnosis as entered by ED clinician plus stroke chameleons) with

NEWS below criteria 1.

4. GI bleed (diagnosis as entered by ED clinician and not considered suitable for

discharge on G-B score) with NEWS below criteria 1.

Palliative patients or those with very poor pre-morbid function are excluded as they are

unlikely to benefit from the enhanced services at CIC. Clear evidence-based

Treatment Escalation Plans which take into account frailty will ensure standardisation

of care: these would be piloted in community settings to facilitate direct diversion of

patients where appropriate.

6 Detailed definitions and criteria to be developed

24

(It should be noted that further consideration could be given to those patients who may

well clinically benefit from CIC additional resource but who could not reasonably be

identified at first assessment; this may include some patients with lung cancer, liver

and other gastro-intestinal problems. These patients have not been modelled in at this

point.)

This option will shift some volume of activity between the sites, but more importantly

will allow those patients at greatest risk to be managed on a site where there is robust

(and more substantive) senior and specialised medical support as well as access to a

range of specialist support services. There is evidence that consolidated delivery

within larger specialised teams would enable greater standardisation and achievement

of high quality care. The options would require a shift in emergency beds and

associated resource from WCH to CIC. This would be offset by anticipated increase in

low risk elective activity and outpatient/ambulatory activity at WCH.

Operational Delivery of an Integrated Urgent Care System at Night

In the envisaged UC1 admissions system, and in keeping with the agreed concept of

an ‘Emergency Floor’, the H@N team at WCH works across all professional and

specialty boundaries. This would operate with a single consultant responsible across

ED/Medicine ‘front’ and ‘back of house’. Although during the day when the units are

busier there continues to be more traditional staffing, this way of working at night is

well suited to doctors with generalist skills i.e. trainees (before specialty formation),

GPs (CHOC7), A&E consultants, General Physicians, and ACPs. Staff are supported

by specialty pathways and opinion, either locally or from CIC. Led by Medicine, the

team’s role is to ensure that correct initial treatment is initiated, that patients are

triaged correctly into pathways based on risk and presentation and that their passage

through the system is expedited. Managing this front of house workload together

allows the team to share patients, develop and maintain skills and sustain work

interest. They will work within the newly built ED/EAU/Assessment Unit ‘emergency

floor’ at WCH and meet as a team at H@N shift change. It also allows for staff

undertaking similar roles to cross cover and reduce cost from the whole system. This

system is supported by nurse practitioners/F1s, and includes a consultant physician

on call from home.

Potential specialty doctor medical workforce associated with this model would only be

expected to only when the unit is at its quietest i.e. from 2200 to 0800.

Following a period of stabilisation and familiarisation, consultant out of hours cover

may potentially be provided cross-Trust by a single integrated rota plus 2nd consultant

‘back-up’.

7 CHOC – Cumbria Health On Call: GP out of hours provider

25

Options UC2 (a-e) – Managing Volume

Additional mechanisms could be used to further de-risk WCH by reducing volumes of

acute medical patients at the WCH site by transferring patients according to time of

day and/or home postcode in addition to changes as described in UC1:

Limited Hours for Receiving Emergency Admissions

A way to manage potentially high volumes of general medical patients requiring input

from relatively junior staff would be to restrict non-elective admissions to the site

during the day and/or at night. This could be either on the basis of purely a 999 “blue

light” divert, with the site continuing to accept GP referrals and walk-in patients

requiring admission, or could include all those requiring a front of house medical

assessment.

Diversion of Patients Based on Postcode

Whilst the Ambulance Service had historically taken patients to the nearest Accident &

Emergency Department, the introduction of clear guidelines empowered crews to

divert to a specialist centre, which may have a longer journey time but which is

expected to provide improved clinical outcomes. Similarly, local GPs generally make a

referral to their nearest hospital, although there are clear pathways for selection of a

particular site in some instances. This deliberate diversion is already built upon in

UC1.

When one site is experiencing high attendances or bed availability is limited, a ‘post

code divert’ system is currently used for a limited period of time to improve patient

flow. If UC1 was considered insufficient to fully address current challenges, this

approach could be used to manage volumes on an ‘as required’ (for example if current

locum medical staffing deteriorated) or even permanent basis. A number of patients

live in areas relatively equidistant between sites; a transfer of routine admitting site

from WCH to CIC (i.e. a marginal postcode shift) may make minimal differences to

patients, their visiting families and ambulance services, but considerably relieve

pressure on the WCH site (given current fragility of medical workforce).

There are various possible permutations, but for modelling purposes additional options

are identified as:

a. All blue lights transfer to CIC between 21.00 and 08.00

b. All acute admissions including GP and self-referrals transfer to CIC between

21.00 and 08.00

c. All acute admissions including GP referrals and self-referrals transfer to CIC

between 21.00 and 08.00 PLUS marginal postcode shifts during day

d. Marginal postcode shifts alone at night only

e. Marginal postcode shifts alone all times of day

26

Activity Changes & Bed Capacity

Assumptions & Modelling

The following high-level modelling undertaken on the high risk medical pathways has

been validated by Price Waterhouse Coopers; it has deliberately erred on the side of

caution in other words by other estimating where there is room for doubt. However

further more detailed modelling and scenario analysis will be required. For the

purposes of modelling it is assumed:

current NEL presenting activity and proportion of required admissions remain

in line with 2013/14 for WCH;

whilst the medical workforce changes in WCH surgical teams from August

2014 are factored into the baseline, other anticipated pathway changes

(potentially reducing surgical admissions) do not immediately occur.

Bed capacity work for Option UC1 & 2 assumes:

Repatriation to WCH after average 3 days LOS following transfer to CIC;

85% bed occupancy;

Some patients deteriorate on EAU/base wards at WCH and may need to be

transferred – a cautious over-estimate of ‘worst case’ is modelled

UC2 options all INCLUDE bed shifts relating to UC1.

Night time admissions defined as occurring between 21.00 and 08.00

UC2a based on admissions to WCH for majors arriving by ambulance

Postcode shifts based on ambulance and GP referred arrivals from specified

ward

The table below shows anticipated additional transfers/diversions from WCH to CIC for

UC1 patients over and above patients already transferring from WCH:

Additional CIC patient transfers :

Transfers/diversions per year

Transfers/diversions per week

Transfers/diversions per day

UC1:

High risk pathways

444 8.5 1.2

NEWS (including transfers from EAU/wards)

600 11.5 1.7

TOTAL 1044 20 3.0

27

UC2 modelling includes the transfers associated with UC1 i.e. it sets out the

cumulative impact of the options. Modelling has adjusted to remove potential double

counting with UC1:

Additional CIC patient transfers :

Transfers/diversions per year

Transfers/diversions per week

Transfers/diversions per day

UC2a - All blue lights at night

1,486 28,5 4.1

UC2b - All acute admissions at night

3,306 63,4 9.1

UC2c All acute admissions at night plus postcode shifts all times

4,083 78.3 11.2

UC2d - Postcode shifts at night

1,450 27.8 4.0

UC2e - Postcode shifts all times

2,228 42.7 6.1

For the transfers/diversions modelled at UC1 it is likely that circa 35% of these would

take place between the hours of 21.00 and 08.00.

The table below summarises the anticipated associated bed requirement changes:

28

Note: UC2 shows the cumulative impact of the options – i.e. includes UC1 changes

The estimated additional impact of shifting ongoing management of patients with

identified high-risk pathways and high NEWS scores from WCH to CIC (UC1) is

therefore a fairly modest requirement for 10 additional beds with a saving of 10 beds

at WCH. Volume shifts achieved through Option UC2 inevitably have a greater impact,

with night closure requiring more than 30 additional beds at CIC from current

requirements.

The impact of out of hospital scale and whole system service integration is anticipated

to reduce bed requirements over time, irrespective of the option chosen. However, at

the current time no substantive plans or modelling of the impact of this are available.

Workforce

Essential to successful operational delivery of UC1&2 options is the principle of a

single front of house medical workforce, operating as an integrated team across ED

and EAU both in and out of hours.

Current Workforce

WCH Acute Medicine/Front of House & Back of House:

WCH A&E currently 3 tier. WCH A&E consultant cover at weekends is

intermittent between 08.00- 22.00; there is middle grade cover at night 7 days

per week.

Consultant cover for WCH acute medicine both front of house and back of

house is currently provided from 7 consultants providing a mixture of Acute

Care Physician (ACP), stroke, elderly medicine, respiratory, cardiology and

Beddays WCH Beds WCH +/- Beddays CIC +/- Beds CIC

UC1: Designated High Risk Pathways and NEWS

High risk -1,476 -4.8 1476 4.8

NEWS -1,800 -5.8 1800 5.8

UC1 Total -3,276 -10.6 3276 10.6

UC2a: All blue lights transfer to CIC between 21.00 and 08.00:

-4,458 -14.4 4,458 14.4

UC2b : All acute admissions incl. GP referrals & self-referrals transfer 21.00 to 08.00:

-9,918 -32.0 9,918 32.0

UC2c All acute admissions at night plus postcode shifts all times

-12,249 -39.5 12,249 39.5

UC2d: Marginal postcode shifts at night only:

-4,350 -14.0 4,350 14.0

UC2e: Marginal postcode shifts all times of day:

-6,684 -21.5 6,684 21.5

29

general medicine on call: 5 ACPs work 8am-6pm on weekdays, with physician

of the day presence until 10pm.

There is consultant presence at weekends covered by Locum Physician of the

Day from 0800-22.00; overnight cover is provided 6 nights out of 7 and all

weekends by Locums.

4 middle grade doctors in medicine at WCH provide 24 hour cover over 7 days

a week; CTs/GPVTS cover acute medicine working to a 1 in 9 rota.

F1 Acute Medicine doctors covering the Back of House rota have been

replaced (August 2014) by Nurse Practitioners supported by Consultants.

Nurse Practitioners also provide back of house 24/7 support to medical and

surgical wards with a further 7 working in ambulatory care.

7 F1 Doctors continue to cover Front of House during the daytime where they

receive training and supervision from a Consultant. From August 2015 the F1

Front of House role is covered by Nurse Practitioners supported by the GPVTS

grade of Doctors and ACP

Emergency General Surgery:

Consultant presence 8am to 6pm and 9am -12pm at weekends

Middle grade cover 8am-8pm 7 days per week

After 8pm, Hospital @Night Team cover to wards, with specialty surgical

emergency assessment support/provision from CIC

1 consultant for anaesthetics/ITU on-call for all streams, plus 1 resident middle

grade (all streams), plus 3rd tier consultant provision for contingency cover

CIC:

CIC acute medicine includes ACPs between 8am and 10pm, resident middle

grade medical cover and a consultant on-call from home.

2 consultant anaesthetists on-call – 1 for ICU, 1 for theatres/maternity. 1

resident middle grade OOH plus ICU consultant on-call from home and only as

required at weekends; A&E anaesthetics cover until 22.00.

Option UC1

It is proposed that implementing a transfer process for High Risk Patients to CIC and

reducing the acuity of non-elective admissions at WCH, coupled with the right

combination of Consultants, ACPs, GPVTS and Trust Doctors and Nurse Practitioners

covering Front and Back of House will ultimately allow removal of locums whilst

maintaining acute medical services

Single medical workforce at night operating as an integrated team with staff

generalist competencies that undertakes triage assessment and immediate

management for surgery and medicine across an integrated front of house.

Work is already progressing to develop attractive joint posts with primary care

colleagues to provide stability and a substantive tier at CT/GPVTS level.

30

After a period of stabilisation arrangements could move from 2 separate

consultant rotas for each site, to a single consultant physician on-call rota from

home with a second on-call back-up in operation. This change could have a

major positive impact on sustainability.

Movement over time towards an integrated model for ED consultant workforce

cross-trust.

Assumes additional front of house workload of 3 patients per day at CIC can be

absorbed within current medical staffing levels.

Over time, high acuity/ICU beds and outreach service are managed by a

Critical Care Nurse Practitioner supported by a resident middle grade

intensivist/anaesthetist including transfer/retrieval team and consultant on call.

(In the event of no on-site ventilated patients and no obstetrics, there may be

potential for remodelled utilisation of medical and nursing roles to manage the

high acuity and HDU beds 24/7)

Option UC2

If WCH were to accept no overnight admissions (UC2b) it is assumed that this would

allow further consolidation of the ED/Front of House medical workforce at WCH, and

of ED on-call at CIC with reduction in consultant on-call requirements cross-trust: there

would then be an expectation over time of integrated Front of House consultant on-call

rotas cross-site, and flexible use of available substantive consultant staff based on

competencies, changing over time to dual trained recruitment where possible.

Other UC2 variations would not make any additional substantive change to the

medical workforce model (aside from that required to support back of house beds).

Clinical Support, Estates & Facility & Issues

Clinical Support

It is assumed that there would be no net impact on pathology and radiology services

across the Trust; it will however be critical for early involvement of clinical support

colleagues in any detailed plan development. The siting of major surgery (and

obstetrics) has implications for blood transfusion service and delivery. This will also be

relevant if major GI bleeds are consistently to be transferred from WCH to CIC.

Depending on what else is required at the WCH site, there may be a need to modify

stocked levels of O negative blood for stabilisation pre transfer purposes.

The vision for critical care anticipates a journey over time, making optimal use of

available WCH and CIC resources to support changes, with anticipated gradual

reduction (but continued as necessary) Level 3 activity at WCH, increase in Level 2

provision and with converse changes at CIC. This includes long-term

capacity/capability to stabilise, ventilate and manage Level 3 patients until such time

as care is appropriately transferred. Care will be designed to ensure Intensive Care

31

Standards8 can be fully met, and key to this is safe transfer between sites, and an

increase in CIC capacity:

Critical Care beds at WCH would operate as a continuum with higher acuity

beds used (a) as support for unstable/ deteriorating medical patient (or surgical

with medical complications); (b) for care for sicker patients from front of house

who are not transferred including severe sepsis; (c) for patients repatriated from

CIC ICU once stepped-down from organ support; and (d) for potentially small

numbers of new elective patients: for example, revision hip arthroplasty. All

local patients requiring NIV would be managed in ICU facilities.

CIC activity has already increased as a result of transfer of high risk surgical

pathways and elective demand. The 4 designated high risk medical pathways

are unlikely to significantly impact on critical care demand although those with

high NEWS scores will: it is estimated that UC1 would result in an additional

100 patients with a CIC critical care stay. These patients are likely to be at the

higher acuity end with an estimated average LOS of 4.5 days. This represents

450 bed days or 1-2 additional beds.

Whilst this additional demand on top of existing increased pressures will

necessitate facility expansion at CIC it is currently assumed that there is no

overall net increase in critical care bed requirements across the Trust.

Containment is expected to be achieved through a combination of reduced

Level 3 demand at WCH with more flexible and integrated use of high

acuity/HDU & CCU beds within the new facility, including different management

of overdose patients, transfer of stroke patients and changes to paediatrics. It is

not anticipated that increased elective activity at WCH would significantly

impact on critical care demand given the need to ensure a casemix where there

is minimal risk of requiring return to theatre.

Consideration needs to be given to appropriate staffing for patient retrieval.

Estates & Facilities

It is proposed that high risk medical patients transferred to CIC at UC1 will be

managed on the second floor with all patients initially managed through Larch A/B

prior to transfer to specialty wards:

Acute stroke – Elm A

ACS – Willow C/CCU

GI Bleed – Beech A

NEWS 5> - Larch A/B

To achieve the optimal clinical outcomes being sought will require careful

consideration of speciality requirements and configurations to ensure we can place

patients in the ‘right bed’. In advance of longer-term re-configuration of the CIC estate,

8 The Faculty of Intensive Care Medicine/Intensive Care Society, Core Standards for Intensive Care Units, 2013

32

this will require the transfer of bed space for 10 patients from the second floor

environment into alternative accommodation.

Longer term a business case is being developed (value circa £30m) to create a new

fifth Pavilion at CIC to house A&E, EAU, ambulatory care, cardiology services

(including CCU the Cath Lab) with reconfiguration of other services to improve clinical

adjacencies, infection control and patient experience. These proposals could be

developed to ensure capacity for UC2 requirements.

The acute bed reductions in UC1 &UC2 at WCH would be netted off against the 30

acute and sub-acute medical bed base modelled into the WCH Redevelopment

Business Case, noting that the staffing requirements are not identical. This would

ensure flexibility to manage planned increases in elective workload over time. Any

further (probably sub-acute) changes to bed requirements would need to be modelled

once anticipated increased primary/community care capacity takes effect.

Option Appraisal and Discussion

As highlighted in local Risk Summits and in the Chief Inspectors of Hospital’s report,

there are significant and unacceptable risks in continued delivery of services operating

to the current model due to the ability to recruit and retain sufficient substantive

medical staff. Services at night following changes to junior and non-medical staff from

August 2014 have been secured through a Nurse Practitioner H@N model but whilst

currently safe, arrangements are very fragile given their reliance on locums, posing a

risk in maintaining safe management of unselected medical admissions (both in terms

of complexity and volume) in the longer term. Without change to the casemix and

volume of current non-elective medical activity, the middle grade tier at WCH (which is

currently fully made up of locum staff) will continue to be required with little prospect of

substantive recruitment. This creates a cost pressure in excess of £1.0m per annum,

in addition to the quality impact on patient care.

Introducing a system for transfer/diversion of high risk patients as in Option UC1 safely

manages the current WCH workforce risks by day and night with reduced locum

reliance. This would be the clinically preferred option as it explicitly seeks to improve

clinical outcomes for high risk patients as opposed to a pathway decision based on

service necessity. The model continues to retain resident anaesthetic/intensivist

support for front and back of house necessary to safely run an unselected A&E. (Note

the obstetric/neonatal issues in relation to running multiple anaesthetic streams).

Unnecessary patient journeys can be avoided by maximising the patients who can be

identified prior to arrival at hospital in community settings and directly diverted to CIC,

although clearly there is still impact on relatives’ journeys. The initially anticipated (and

modelled) additional length of stay for patients transferred/diverted can be mitigated by

access to better diagnostics and other resources at CIC and increasing integrated

working with community providers both facilitating swifter discharge.

33

This model of care will see the Trust much better placed to meet the challenges of 7

day working within the nationally required timeframes.

Options UC2a & b further reduce on-site risk at night for WCH but would result in more

clinically unnecessary travel for patients and inconvenience for their relatives. There

may also be difficulties in operationally managing differences in pathways at differing

times of the day. However, if substantive recruitment at WCH proves impossible it may

present the only safe option.

Diversion of GP referrals/ambulances from current postcode destinations as in UC2c-e

can be flexed as required with arguably minimal differences to journey times. All UC2

options merely shift volume as a way of managing workforce challenges – they do not

anticipate improved clinical outcomes for individual patients resulting from the change.

Although clearly if used to manage any increased risk at WCH would, by definition, be

expected to improve outcomes.

Options are assessed against the key criteria necessary to secure long-term clinical

and financial sustainability. Other possible criteria in relation to local access, patient

preferences and political implications are not included at this point with a focus purely

on core service requirements:

Criteria: Current UC1 – Transfer High Risk Pathways & NEWS

UC2b – Close WCH to overnight admissions / time of day/postcode diverts

Deliver safe pathways for patient care

Some risks

Meet all required quality and other regulatory standards

Be practicably and sustainably implemented in workforce terms

Likely

Contribute to reduction in structural deficit

Overall Initial Ranking: (1= preferred)

3 1 2

Initial ranking would support transfer of certain high risk medical patients in addition to

existing surgical pathways from WCH to CIC as in UC1.

34

Obstetrics & Midwifery: Intrapartum Care including

Neonatology

Current Service

Obstetric care is provided at both Trust sites with 1686 births at CIC in 2013 and 1313

at WCH. Each service has dedicated staff and there is no cross-over for emergencies.

Day assessment unit services are provided on both sites. Additional midwifery led care

is provided at the Penrith Birth Centre and throughout the community including choice

of home births. A review of midwifery services in 2012 has enhanced provision with

the creation of specialist midwifery and supernumerary posts and a robust

preceptorship programme.

Five consultants contribute to obstetrics and gynaecology services on both sites, the

clinical director working across both. This allows 40 hours per week dedicated

prospective presence and a 1 in 5 delivery suite rota with 1 post currently covered by a

locum consultant to backfill the Gynaecology/Oncology Lead Consultant. A further

consultant is covering a middle grade vacancy at CIC.

Proposed Clinical Pathway Options

It is assumed that whatever the outcome of the planned Independent Maternity

Review, changes will be needed in line with one of the potential options outlined

below. All options are expected to operate as part of a Cumbria-wide maternity

network including community-based provision. Community midwifery care, plus

antenatal and postnatal clinics would continue to be delivered at all existing sites, with

expansion where at all possible to improve access to local services. Option appraisal

relates only to the delivery/birth (Intrapartum) element of care.

The option of a single obstetric unit at WCH and no intrapartum provision at CIC is not

modelled: this is not a feasible option given (i) previously consulted-upon decisions to

centralise high risk pathways at CIC and (ii) distance from specialist emergency

support. Both these factors would prevent safe intrapartum management of higher risk

patients in Cumbria in this model, as well as denying the greatest number of patients

local access.

Option OB1 – Enhanced 2 Site Consultant-led Intrapartum Care

In this Option the current regulatory compliance and quality issues have been

addressed through the enhanced provision of anaesthetic support and through a

dedicated obstetric theatre. An MLU would operate immediately adjacent to the

consultant unit, with a degree of shared resource and ability to manage primigravida

patients due to its co-location.

35

Option OB2a – CIC Consultant-led Intra-partum Care plus WCH MLU

All women identified as at higher risk and potentially requiring intrapartum consultant

input, including all primigravida patients, are managed at CIC. An MLU is provided at

WCH for low risk multiparous patients9. Women requiring/requesting epidural would

need ante- or intrapartum transfer to CIC. This option would require transfer of some

women/babies in labour and post-natally to the Obstetric Unit. There would be no

Special Care Baby Unit (SCBU) on site, with care for neonates provided by an

appropriately trained midwife at all times. WCH would provide antenatal care and,

subject to further clinical discussion, potentially planned (low risk) caesarean sections.

Option OB2b – CIC Consultant-led Intra-partum Care plus standalone Allerdale

MLU

All women identified as at higher risk and potentially requiring intrapartum consultant

input, including all primigravida patients, are managed at CIC. A standalone MLU is

provided in Allerdale for low risk multiparous patients. Women requiring/requesting

epidural would need ante- or intrapartum transfer to CIC. This option would require

transfer of some women/babies in labour and post-natally to the Obstetric Unit. There

will be no Special Care Baby Unit (SCBU) on site at WCH, with care for neonates

provided by an appropriately trained midwife at all times.

WCH would continue to provide antenatal care as well as the Allerdale Unit.

Activity Changes

The intrapartum activity anticipated from the different models is shown based on best

practice criteria and national percentages for women suitable for MLU delivery10:

Current Model OB1 OB2a OB2b

WCH

CIC Other

WCH

CIC Other

WCH

CIC Other

Aller

CIC Other

Births11

1278

1698

41 1278

1698

41 336 2640

41 336 2640

41

This activity assumes no loss of market share and no increase in home/birthing centre

births.

9 Royal College of Midwives, Freestanding Midwifery Units, Local high quality maternity care: Busting the Myths,

2014 10

Royal College of Obstetricians’ & Gynaecologists, Reconfiguration of Women Services in the UK, Good Practice No. 15, December 2013 11

Total births assumed are based on trend not 2013 figures

36

Workforce

Workforce modelling will be based on Birth Rate Plus, RCM Guidance Paper 2009 and

Safer Childbirth, 2007. Assumptions for the models include:

Option OB1 - Enhanced 2 Site Consultant-led Intra-partum Care

24/7 dedicated anaesthetic cover both sites.

2nd maternity theatre both sites

Epidural provision both sites (an EWTD compliant rota for a full obstetric

service including epidural requires a minimum of 8 staff).

Staffing for 2 elective LSCS lists adequately covered at WCH.

Option OB2a & OB2b - CIC Consultant-led Intra-partum Care plus WCH MLU/

standalone MLU

24/7 dedicated anaesthetic cover at CIC.

Midwives 24/7 across the MLU/CLU at CIC, and standalone MLUs

It is noted that MLU staffing is dependent on exact model chosen.

Proposed changes at OB2a & 2b anticipate the ability to secure a more permanent

consultant workforce in 3 years.

Medical Staffing Special Care Baby Unit (SCBU)

The overall provision of SCBU is inextricably linked to the medical staffing of the

paediatric department, and the overall paediatric medical staffing requirements will be

dependent on obstetric options. Workforce implications for the chosen model largely

(but not wholly) relate to nursing requirements, with deployment of neonatal nurses to

the obstetrics centre(s) in line with the chosen model.

Facility & Clinical Support Issues

It is assumed that an enhanced model with co-located MLUs would require revision of

current facilities to create an appropriate and separate MLU environment.

Single site obstetrics as at OB2a and OB2b would require significant re-configuration

of space at CIC to accommodate the anticipated additional 942 births, including an

MLU facility.

An MLU at WCH as in OB2a could be relatively easily accommodated within plans for

WCH redevelopment; a standalone MLU as in OB2b would require significant capital

investment, as well as ongoing revenue commitment.

It is assumed that there would be no net impact Trustwide on clinical support

requirements arising from implementation of OB1 or OB2a. There would however be

clinical support implications for a standalone facility as at OB2b which would need to

37

be appropriately modelled; these would include imaging, pathology and pharmacy

support as well as ancillary support services. The siting of obstetrics has implications

for blood transfusion service and delivery.

Option Appraisal & Discussion – Consultant-led Intrapartum Services

Whilst a 2-site consultant service would be preferable in terms of local access for

patients it is with reluctance that the Board’s initial opinion is that this is likely not a

realistic option for the medium-long term future. The principal issue relates to

anaesthetics: to secure a regulatory compliant and safe 2-site service in the longer

term as described at OB1 requires significant recruitment of Trust obstetrically

competent anaesthetists. To provide dedicated resident anaesthetic cover for

obstetrics out of hours on both sites, plus 12 consultant PAs per week for emergency

work on delivery suite as well as elective LSCS cover would require potentially up to

16 more anaesthetists (consultant and middle grade – estimated at 12 at WCH and 4

at CIC).Irrespective of any additional funding opportunities, success in recruiting to

such a number of additional medical posts is highly unlikely – even if posts were made

more attractive by separation of maternity/ITU cover. The Trust has repeatedly been

unsuccessful in recruitment of Trust grade doctors, likely due in part to the

unattractiveness of out of hours responsibilities, alongside the other local factors of

professional isolation and low volumes to maintain skills and develop specialist

interests.

Despite sustained efforts driven by a common desire to maintain 2-site provision, no

model for ITU/Anaesthetics has been identified to date that is both sufficiently safe

and can be practically implemented. The challenge is inextricably linked with future

arrangements for acute medicine – whilst it is envisaged that a resident anaesthetist is

maintained at WCH they would only be able to run one stream of care, not two – this

then points to a judgement call in relation to the preferred stream to maintain.

For obstetrics, this situation is further compounded by difficulties in recruitment to

middle grade and consultant obstetricians. The position is highly unlikely to change in

the foreseeable future.

The Board has considered at length how consultant led intra-partum services might

conceivably be maintained on 2 sites. The challenges of this have been much debated

both internally and externally with commissioning partners and others, with the Board

very keen that the Independent Review should take place as soon as possible, and

also cognisant of its responsibilities to ensure appropriate risk mitigation plans are in

place. However, and in advance of this Review and further work, the challenges are

considered by the Board at this early stage to be such that a 2 site model appears

impossible to deliver against current regulatory guidelines and NICE guidance.

If consolidation of obstetric intra-partum services onto 1 site were to be ultimately

agreed it is considered that due to availability of other services, in particular dedicated

38

anaesthetic/intensivist streams and surgical services, plus distance to the tertiary

centre, single–site consolidation would necessarily be at CIC.

Consideration has been given to how access for our expectant mothers living in West

Cumbria could be additionally enhanced if obstetrics were consolidated at CIC. The

option for an MLU at WCH whilst attractive, is considered by some senior clinicians to

pose a small but unacceptably high risk given its distance from the consultant-led unit,

as well as poor patient experience for women and babies requiring intrapartum or

post-partum transfer. This is an opinion which greatly concerns the Trust Board. On

the basis of peer reviewed research, these risks may be reduced to more acceptable

levels by siting the MLU in Allerdale far closer to the consultant-led facility.

However, to support this option still requires additional consideration of how the

possible impact on perinatal mortality from longer travel times can be mitigated

against, noting that distance from mother’s homes as well as from the MLU is relevant

in this context. The Trust would expect to learn from the experience and solutions in

other countries such as Scotland; this would include excellence in antenatal/postnatal

care and risk assessment, and enhanced travel and possible hotel arrangements as

key, with choice maximised where at all possible for lower risk deliveries.

Our aims at all times will be to minimise risk, deliver care locally wherever possible

and maximize women’s choices

Assessment of the possible options is shown below against the key criteria necessary

to secure long-term clinical and financial sustainability. As before, other possible

criteria in relation to local access, patient preferences and political implications are not

included at this point with a focus purely on core service requirements.

Criteria:

Current OB1- Enhanced 2 Site Obstetrics

OB2a – CIC CLU/MLU & WCH MLU

OB2b – CIC CLU/MLU & Allerdale MLU

Deliver safe pathways for patient care

?

Meet all required quality and other regulatory standards

Partially met

Be practicably and sustainably implemented in workforce terms

39

Contribute to reduction in structural deficit

Not formally ranked given awaited independent maternity review

- - - -

To make a fully informed and final judgement on obstetric challenges requires an

understanding of the findings of the Independent Maternity Review and further

detailed work with clinicians to consider all possible options and their implications, with

any decisions founded upon a firm evidence base. However, and notwithstanding the

outcome of the Independent Review, based on evidence available to date (and

acknowledging that the model may still be relatively expensive) OB2b is believed to be

the safest sustainably implementable option at this current time. Such a consolidated

consultant-led intra-partum delivery unit configured as part of a Cumbria Maternity

network would require rigorous mitigation of issues/risks caused by increased travel

for delivery, excellence of care throughout the perinatal period, with choice to enable

local provision for lower risk mothers wherever possible through home births and an

MLU.

As a service of significant patient/public interest, any proposed changes would require

comprehensive user engagement and public consultation led by commissioners;

temporary changes could potentially be required in advance of this in order to maintain

patient safety but would be avoided if at all possible.

It must be stressed that this opinion has been formed in necessary response to

the challenges posed and will be re-visited in light of the expert Review findings.

The Trust remains open-minded to consideration of alternatives which can

demonstrate they better meet the current challenges of consultant-led

provision.

40

Paediatrics

Current Service

The Trust provides paediatric assessment and inpatient services on both sites from a

total capacity of 39 beds. CIC has 24 acute paediatric beds, which operate as 8

assessment beds and 16 inpatient beds from 08:00 hrs – 20:00 hrs, and overnight

with 16 inpatient beds only. WCH has 15 acute paediatric beds, which operate as 8

assessment beds and 7 inpatient beds from 08:00 hrs – 21:00hrs; overnight it

functions as a 15 bedded area. The WCH new development is planned to provide 7

assessment beds and 7 inpatient beds as a 24/7 service.

The current medical rotas at WCH provide a three tier approach six days per week,

currently working with an SHO, speciality doctor, PNP and consultant resident on call.

At CIC consultants are called in from home in an emergency, with very limited middle

grade support.

There are approximately 44 children per day attending NCUH A&E departments12 of

which 40% (18) are at WCH. 25% of these are for medical conditions as opposed to

injuries, and of these 50% are admitted. 50% of unplanned paediatric admissions are

from GP referral. In 2012, 16% of WCH paediatric patients stayed more than 48 hours,

equivalent to 9 per week - these numbers will be lower now as some young patients

with trauma or with surgical needs are already being directed to CIC as a result of

changes of the trauma and surgical pathways.

Proposed Clinical Pathway Options

The Trust paediatric services represent a small but key part of overall child health

provision in North Cumbria – community, tertiary and intensive care elements are and

will remain integral to Trust arrangements. Care Closer to Home previously supported

the development of short term paediatric and assessment services on the WCH site

with the main paediatric inpatient unit to be provided at CIC. The model is one of

‘assess & treat’ with an expectation of increased outreach and community support.

Most elements of future acute service provision are clear but the hours of functioning

of an assessment unit at WCH have remained outstanding and are the partial focus of

the options set out. (It is noted however that there is a clinical argument for acuity

rather than length of stay influencing best management and this issue also requires

consideration.)

A 48-hour Unit option has not been modelled separately: this would require the same

staffing levels as current with additional enhancement in order to comply with College

Guidelines. Given that the vast majority of children are discharged within 48 hours, the

option would require transfer of a maximum of six children per week. (This is likely to

have been over-estimated given (a) that most of these children would not necessarily

be expected to stay more than 48 hours at the point of admission but may end up

12

Note – this is based on 2010 data

41

doing, and (b) impact of a different SSPAU model of working, for instance mental

health patients and children needing IV antibiotics.)

It is noted that paediatric, CCG and CPFT colleagues are currently working closely to

develop an ‘integrated’ model that seeks to meet standards sustainably through

flexible workforce use across organisational boundaries, and anticipates far greater

support for children outside of hospital. Assessment of children would take place in a

variety of settings and not be confined to 2 designated assessment units. High level

modelling of this option is awaited; in the meantime it is accepted that the Trust must

form a view on the options available to address the challenges within the system.

Once further detailed proposals are received it will be possible to review the options

appraisal.

Two potential options are therefore considered in more detail:

Option P1 - 24 hour WCH Short Stay Paediatric Assessment Unit and

paediatrician access plus low acuity beds

14 assessment beds and low acuity beds integrated with enhanced community

provision and CIC support

The unit would be open for assessment of patients 24 hours per day with local

Consultant cover out of hours.

All urgent/emergency for higher acuity needs will be referred/transferred to the

preferred tertiary care centre or the inpatient unit at CIC for further management

Paediatric day surgery would continue and where possible be expanded

subject to clinician agreement

The proposed changes in P1 anticipate the ability to secure more permanent

consultant workforce.

Option P2 – 14 hour WCH Short Stay Paediatric Assessment Unit (SSPAU) plus

24/7 paediatrician cover

Unit open from 08.00hrs to 22.00hrs 7 days per week – 14 assessment beds

integrated with enhanced community provision and CIC support.

08.00 start accommodates day case activity.

Children requiring longer stays would be referred/transferred to CIC which

would therefore require additional bed capacity.

All emergency care out of these hours would default to A&E/intensivists and

Cumbria Health on Call (CHOC) for immediate management and/or transfer to

CIC. This arrangement would be additionally supported by local 24 hour

paediatrician access.

Given the presence of paediatricians on site at WCH during the day time,

paediatric day surgery could continue and where possible be expanded subject

to clinician agreement

42

In either model the WCH SSPAU would be staffed by experience Nurse practitioners

and day time consultant presence with no reliance on junior/middle grade staff.

Additional nurse support would be required to escort patient transfers to CIC, plus

staffing for overnight beds re-designated from assessment. At CIC there will be

continued requirement for either a resident paediatrian or, if feasible in terms of

investment and training PNPs, as well as 2-site consultant on-call. Higher acuity

patients at CIC will require the right level of medical support with an experienced

‘middle grade’ tier of nurse pratitioners and specility doctors. Both options would take

into account additional staffing requirements in order to meet college guidelines:

Additional paediatric consultant cover to ensure on site present from

10.00-22.00 Monday to Friday, plus 09.00-12.00 and 18.00-22.00 at

weekends

Junior doctor at CIC 08.00-22.00

Additional play specialists

Additional nurse practitioners

Additional nightime qualified and unqualified nursing.

Activity Changes

Current Activity at WCH: There has been no significant increase in admissions over

the last 12 months, but a higher percentage of children discharged within 12 hrs:

LOS Fairfield ward 0 <6 Hrs 6 <12 Hrs

12 to 24 hrs

>24 hrs Total % <12hrs

12/13 E&NEL admission 401 257 708 777 2143 30%

13/14 E&NEL admission 524 289 726 618 2157 37%

Using the above table and similar assessment models from other areas assumptions

have been made regarding the possible impact of the SSPAU model on transfer and

occupancy at CIC. Clinical decision-making regarding need for admission is currently

made on the model of acute care available. A change of model will influence the

management of children’s admission and discharge requirements, with anticipated

fewer children requiring admission and consequently fewer transfers. These numbers

therefore reflect likely upper limits:

Option P1 – 24 hour SSPAU plus Low Acuity Beds – Based on the work of our

buddy trust, NHFT, experience of Gateshead Health NHS Foundation Trust and the

43

above 13/14 activity patients it is likely that 80% of current activity could be managed

locally circa – equating to 431 transfers per year, 8.3 per week, or 1.2 per day.

Option P2 – 14 hour SSPAU - 19% of paediatric admissions of less than 12 hours

were admitted at night13. Including these, a total of c1500 patients (1344 +156) would

need transfer to CIC: approximately 4 children per day (29 per week). This estimate

has been adjusted to take into account need to have completed safe transfer prior to

unit night closure.

Facility & Clinical Support Issues

With current midnight occupancy at CIC based on 16 overnight beds at 60%, and an

assessment unit model with rapid assessment and ‘discharge’, it is considered unlikely

that the physical number of beds in CIC will need to increase at P1 or P2 (although

some current assessment beds would be re-designated as inpatient beds).

It is assumed there would be no net impact on clinical support requirements; however

consideration is needed in relation to appropriate stabilisation and management of

children requiring HDU/ICU care, CIC HDU capacity, and safe transfer to Newcastle,

where this is a more suitable destination than CIC.

Option Appraisal & Discussion

A 24/7 full inpatient service on 2 sites is not considered viable long-term on the basis

of the medical staffing requirements including need for paediatric critical care support,

given difficulties in recruiting both anaesthetists and to a lesser extent paediatricians.

Most importantly, consolidation of in-patient services onto one site is expected to

create a more robust service including appropriate management of ward-based

dependent children. This approach including centralised care for critically ill children,

coupled with local access to high quality assessment provision is in line with the

general direction of travel nationally for delivery of high quality acute children’s

services.

A more robust paediatrician rota could be sustained if the two current rotas combined

and provided cross site medical staffing rotas with just one 24/7 site providing out of

hours on call. However, there is a genuine concern in relation to the management of

very acutely ill-children self-presenting to A&E outwith of SSPAU opening hours as in

P2. These numbers would likely be very small (the vast majority of patients can be

diverted out of hours –see below) and the risk could be mitigated through access to a

local consultant paediatrician at night. Assuming successful recruitment to nurse

practitioner posts, P2 offers the greatest likelihood of the Trust compliance in the long-

13

2011/12 data

44

term with College standards in respect of workforce requirements, although current

paediatric workforce can support P1.

P1 and P2’s success is in part dependent on increased high quality community

support, and this is particularly true for P2 out of hours. However, only 2-3 patients per

day requiring admission present via A&E at WCH and 85% of these are between 9am

and 10pm14 . For those who do present, the integrated front of house workforce

including critical care support would be anticipated in P2 to be able to safely provide

immediate management prior to transfer and/or where appropriate assistance from a

local paediatrician.

For P2 and to a lesser extent P1 safe transfer of children, with appropriate clinical

support and timely response is a key issue particularly for very sick children. The

additional numbers of children requiring transfer in P2 as opposed to P1 are

approximately 2 per day (17 per week). 68% of unplanned admissions are GP

referrals, and 21% arrive by ambulance at A&E with only 11% self-presenting via the

A&E department15; therefore referrals may potentially be immediately diverted to CIC

where it is clear that a longer admission is required as well as outside of SSPAU

hours. Seasonal issues impacting on transfer rates (e.g. children with bronchiolitis),

and the need for early - and potentially unnecessary - transfers must be considered,

as must be the impact on families of long travel times.

Consideration must also be given to length of stay versus acuity requirements and the

justification for transferring children with low acuity needs. In a model with 24hour

paediatric assessment service there is a good argument for provision of low acuity in-

patient beds for those children not requiring continual nursing/medical input – the

precise criteria for ‘low acuity’ admissions would require detailed clinical work.

Other issues which would need to be addressed for P1 or P2 to be successfully

implemented include:

Development and investment in current paediatric staff nurses to achieve

Paediatric Nurse Practitioner status (requirements reduced in P2) to deliver this

new model of care. Whichever option in relation to hours of operation is chosen,

implementation will require considerable lead in time for required nurse

practitioner training.

Need for additional resources to enable increased rapid access clinics or

outreach community nursing support to facilitate earlier discharge. Successful

achievement of this would further reduce tariff income.

Integration of child health provision across North Cumbria. This offers

significant opportunities for both quality and efficiency improvements and would

be expected to reduce admissions over time.

14

Based on 2010 data 15

Based on 2013 A&E HED data

45

Trust wide management of children with HDU-level requirements. Anaesthetic

issues have been explored in the previous section; arrangements to manage

safe airways and to meet standards for children requiring HDU must be re-

visited irrespective of the option chosen.

Whilst not of primary importance in the context of this work, it should be noted that the

volume of activity is insufficient to financially support two in-patient units under current

funding arrangements - a situation which would be further exacerbated by successful

introduction of both the hospital assessment model and out of hospital child health

care. Conversely, staffing requirements may reduce as a result of both swifter

assessment in hospital and reduced numbers requiring hospital assessment.

Options are assessed against the key criteria necessary to secure long-term clinical

and financial sustainability. As previously, other possible criteria in relation to local

access, patient preferences and political implications are not included at this point with

a focus purely on core service requirements:

Criteria: Current P1 - 24 hour SSPAU plus low acuity beds

P2 - 14 hour SSPAU including 24/7 paed. cover

Deliver safe pathways for patient care

Meet all required quality and other regulatory standards

Be practicably and sustainably implemented in workforce terms

Possible

Contribute to reduction in structural deficit

Overall Ranking: (1= preferred)

3 1 2

In summary there is a clear strategic direction for secondary care paediatric services

to form part of a system-wide integrated model of care with increased levels of safe,

46

high quality community based provision, supported by secondary care, a single

inpatient unit, and with a common and localised approach to paediatric assessment.

The SSPAU model forms a key part of this, and for WCH will be delivered by

consultants and nurse practitioners working at a senior level with no reliance on junior

doctors. WCH will continue to have 24-hour access to a consultant paediatrician.

A key issue relates to hours of SSPAU operation. Whilst P2 is most likely to be most

sustainable long-term in workforce terms, there are concerns in relation to

unnecessary transfers of small numbers of sick children at night, as well as

consideration of acuity versus length of stay issues.

P1 if therefore considered the most appropriate option at this time – but noting that

workforce and activity issues may require this model to be re-visited in the future.

Further work and clinical discussion is needed to define and fully model the low acuity

local care provision and to progress a whole system integrated solution for child

health.

Elective Care

Inpatient & Day Case

A core element of the clinical strategy is increase to the non-complex elective and day

case activity taking place at WCH. The aim of this is to:

Maximise the total volume of care that can be provided locally to West

Cumberland patients

Enable successful and sustainable delivery of A&E, Cancer and 18 week

standards through the most efficient use of available elective care capacity

Take advantage of the new facilities and staff skills at WCH to create a positive

choice for elective care for all North Cumbria patients - and potentially from a

wider catchment - with WCH becoming an Elective ‘Centre of Excellence’

Work undertaken to consider day case and elective in-patient activity across both CIC

and WCH has included clinical review of procedures that could be undertaken safely

at WCH, as well as current in-patient activity that could be converted to day case

procedures based upon BADS 25 information. Consideration has been given to

theatre utilisation improvements and theatre/bed capacity requirements. Work is well

advanced for general surgery and urology:

Specialty Theatre Utilisation

Annual In patient cases to move from CIC to WCH (beddays)

Additional monthly Theatre lists required at WCH at 80% utilisation

Annual Day Cases to move from CIC to WCH

Additional monthly Theatre lists required at WCH at 80% utilisation

Current% Proposed%

47

General Surgery

56 80 480 (765) 5 372 8

Urology

52 80 312 (405) 2 396 5

The additional theatre capacity for 8 lists per month (proposed inpatient lists) can be

created from current facilities using Trust-wide staffing resource. Additional capacity

would however be required to cover the day case activity in advance of the new

hospital, but after April 2015 can be absorbed within this facility. Staffing potentially

freed up at CIC may be unavailable if reallocated to manage 18 week backlog

pressures, requiring some additional interim support; this is a particular risk in relation

to anaesthetic staff. Other considerations include the need for radiology support for

pre-operative guide wire insertions and other in-theatre requirements.

Proposed shifts in in-patient activity corresponds to freeing up 4 beds at CIC and

which could be absorbed in the current surgical business unit bed base on Overwater

Ward at WCH. Additional day case theatre lists will require some realignment and

maximised utilisation of the day case and bed facilities. Longer term reconfiguration

can be agreed for when the new hospital opens in April 2015 and which takes into

account changes agreed as described for unscheduled pathways.

Indications are that shift of in-patient activity for general surgery and urology can begin

within the next few months, with day care following once the new hospital facility is

open. Plans are advanced for a shift in (initially non-wire) breast surgery including

reconstructions with a WCH-based symptomatic outpatient clinic for new patients.

Further work needs to be undertaken to scope potential for a shift in gynaecological

work and in orthopaedics, in combination with work to determine sustainable 18 week

delivery post April 2015.

All these anticipated shifts are subject to active patient choice. Other factors and their

costs will need to be fully modelled, although it is assumed that there is no need for

additional HDU support at WCH with the possible exception of care for hip revision

patients.

Outpatients

A significant proportion of outpatients are seen at CIC from Eden, Copeland and

Allerdale localities. Considering only those specialties where more than 1000 patients

are seen from non-Carlisle localities, the table below shows potential volumes for

‘repatriation’ to WCH. Assuming that patient choice already influences location to

some degree a modest potential 50% repatriation is shown. It is however anticipated

that the new build at WCH will provide both additional facility opportunities and likely

influence patient choice to make this shift even greater.

48

Specialty Annual Copeland Patients

Potential Estimated 50% Repatriation

Ophthalmology 1172 586

Orthopaedics 1034 517

Orthodontics 1581 791

ENT 428 214

Breast Surgery 1105 553

Gynaecology 305 153

Rheumatology 325 163

Oral Surgery 489 245

Cardiology 109 55

Radiotherapy 420 210

Dermatology 548 274

Gastroenterology 194 97

Urology 97 49

Dermatology Nurse 401 201

TOTAL 8,208 4,108

It is noted that there will be other possible venues in West Cumberland, including

Cleator Moor, and GP surgeries, although these will not necessarily always be suitable

depending on patient volumes and clinical, facility and/or equipment restrictions. The

objective however is to secure available local access to services for West Cumberland

residents, not to increase WCH site activity per se, so this potential will continue to be

explored as part of clinical strategy. The greater use of community facilities will

ensure sufficient physical capacity remains in WCH outpatients.

Increasingly the Trust expects to see a new model of outpatient delivery, with

specialist provision much more closely integrated with primary and community health

care, working as extended multidisciplinary teams, particularly for patients with long

term conditions. Whilst a different model will change the overall activity in the long

term, this would still be provided locally (whether by the primary health care team or

specialist) and illustrates the significant potential available to partners.

Transport

A new transfer protocol for adults is now in place which has been developed with

NWAS colleagues. A refreshed transfer policy for children is in development. The

need for cross-system work to enable maximal identification of patients prior to

presentation at hospital, and minimise additional hand-offs, poor patient experience

and other inefficiencies is noted.

Discussions continue to progress with North West Ambulance Service (NWAS) in

relation to increased capacity requirements to support potential patient transfers.

Short-term cross-system contingency arrangements already developed with NWAS

colleagues include St John’s Ambulance to provide additional capacity for transfers;

49

however, longer term arrangements would require recruitment of additional staff and

procurement of ambulance vehicles.

The following identifies possible transfer/diversion activity and associated costs:

Unscheduled Care

Current protocols require some transfers/diversions every day. Concentrating high risk

medical services on the CIC site as in UC1 will require additional average

transfers/diversions of around 3 per day; recognising that diversion may be possible

for many. Additional transfers/diversions resulting from overnight closure are in the

order of a further 8.

Consideration also needs to be given to repatriation requirements, including potentially

those patients stepped down from CIC intensive care, as well as onward transfers to

the North East

Obstetrics

With very careful selection of patients antenatally, (i.e. those women who are deemed

low risk and able to safely deliver in an MLU – approx. modelling figure = 336) those

women requiring intrapartum transfer could be in the order of 5-9% (17- 30 patients

per year) – some 1-3 per month. These patients would however require immediate

attention to minimise adverse patient experience and ensure both maternal and

fetal/neonatal safety.

It is estimated that, with appropriate identification of low risk patients, babies needing

post-delivery transfer from a standalone MLU to SCBU would be in the order of 1% -

perhaps only 3-4 patients per year.

Paediatrics

P2 would require a maximum of 26 transfers per week and P1, 12 per week. However,

it is likely that a proportion of these could be diverted at point of GP referral (and

others assessed at WCH may prefer and be suitable to use own transport options).

Consideration will need to be given as to the seasonal nature of transfers, in particular

babies and young children with respiratory difficulties.

Children requiring transfer for in-patient care will need robust pathway management,

with criteria determined by the anaesthetist team, NWAS and Retrieval Team – a new

transfer protocol for children is being developed. In particular arrangements for

increased numbers of very sick children requiring transfer to CIC or Newcastle must

be considered. Consideration needs to be given to the impact of any newly required

transfers to either CIC or the tertiary centre on safety and nurse escort requirements

as well as ambulance transportation.

50

Anticipated transport impact

High-level transport analysis has been undertaken based on work undertaken in South

Cumbria however a number of assumptions have been used which all need to be

validated and is therefore not included yet.

Further detailed discussions with NWAS and modelling will therefore be required to

understand the full impact of potential solutions identified. Discussion is also required

with clinicians in relation to potential for direct diverts to CIC through use of paramedic

assessment and agreed pathways with primary care.

Careful consideration will need to be given with commissioners and transport

providers regarding options and alternatives for:

transfer and diversion of non-elective patients from WCH to CIC

repatriation of patients from CIC to WCH to complete their care

relatives in particular older people and those with young children visiting in-

patients

staff from integrated workforce arrangements and altered service

configurations

any onward transfers required to the specialist centre in Newcastle

The readily available capacity of appropriate transport to support preferred options

presents a key challenge to implementation: it is recommended that the CCG be

requested to commission a discrete inter-hospital transport solution with the

specification developed based on work with the Trust and with NWAS colleagues, and

informed by external scrutiny of proposals by the Chief Executive of South West

Cornwall (where there is a similar rural footprint).

Clinical & System Outcome Measures

The potential way forward for transformational change detailed within this paper would

require close monitoring if implemented to provide assurance to the commissioners,

regulators and the public that they have resulted in the anticipated service

improvement. A number of system measures would be used to track overall

improvement in line with Chief Inspector/CQC, commissioner, NHS TDA and other

requirements. Any chosen service options will need to demonstrate their ability to

meet expected targets and standards and this will form a key part of further options,

discussion and appraisal.

Importantly, it is expected that a reduction in the variation in mortality between the

sites (with necessary casemix adjustment) and potentially further overall relative

mortality reduction will be achieved through agreed changes. This is in line with the

mortality improvements seen to date which are considered due in part to recent

pathway changes for cardiac, trauma and surgical patients:

51

At an individual pathway level the Trust has seen what can be achieved through

consolidation into larger teams, working in more systematic structured ways – there

have been improvements in clinical outcomes for both trauma and cardiology patients.

For example, for patients with fractured neck of femur the average time to operation

from admissions has significantly improved at the same times as a sustained and

continuing reduction in mortality.

Key Performance Indicators (KPIs) to measure outcomes of any potential further

changes described would include:-

1) Mortality rate improvements: with a decreased difference between sites and at weekends

2) Transfer between sites: monitoring of all transfers against agreed standards and criteria; impact on care continuity including LOS

3) WCH Activity: overall increase across all emergency/elective in and outpatient care

4) Medical Workforce: reduction in proportion of locum/agency doctors

Year

Quarter Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Observed 297 288 274 295 303 297 275 321 322 261 249 257

Expected 254.97 249.76 216.62 253.55 259.06 246.25 253.21 277.92 305.21 274.96 264.69 295.23

Key to Step Changes

Oct-12

Dec-12

Dec-12

Mar-13

Mar-13

Jun-13

Jun-13

Start of Primary PCI Service Jul-13

Oct-13

Dec-13Start of Care Bundles

2011 2012 2013

Mortality Review 2011/12

Change to the Production of Discharge Letters

Beginning of Surgical Transfers from WCH to CIC

Opening of PCI Unit

Commencement of NEWS / Deteriorating Patient Group & Harm Group

Implementation of 5/7 ACP both Sites

Beginning of Orthopaedic Transfers from WCH to CIC

Commencement of Patient Safety Panels (Review of Serious Incidents)

0

50

100

150

200

250

300

350

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2011 2012 2013

Observed & Expected Deaths - 2011 to 2013

Observed Expected

B

A

C

A D F

E G IH

B

C

D

E

F

G

H

I

A

B

C

D

E

F

G

H

I

A

B

C

D

E

F

G

H

I

A

B

C

D

E

F

G

H

I

A

B

C

D

E

F

G

H

I

A

B

C

D

E

F

G

H

I

J

J

52

5) NHS Forum 7 day Services: compliance with national clinical standards 6) Regulatory standards: CQC Compliance

Other specific specialty level measurable expectations will include:

Compliance with Royal College Guidelines and Outcome Measures;

Compliance with NICE standards;

Compliance with HENE requirements for junior support and supervision;

Availability of staff with required competencies/skills e.g. APLS (Advanced

Paediatric Life Support).

Specialties will develop a small number of clinical and other indicators that can be

measured and reported on internally and externally to provide service level assurance.

Indicators will be accepted measures of safety, quality, operational performance and

financial delivery, used in other parts of the NHS and amenable to benchmarking, and

draw on readily available information. This will include care bundles and specialty

performance indicators in use within Northumbria Healthcare NHS Foundation Trust.

These indicators will be routinely monitored as part of Strategy implementation.

Example indicators for Stroke and GI Bleeds may include:

Stroke: Overall SSNAP16 score – aiming for both overall improvement and differential reduction between sites

Door to needle time

Best Practice Tariff attainment

Thrombolysis rate

GI Bleeds: Percentage with upper GI bleeding receiving a risk assessment using validated risk score

Percentage with severe acute upper GI bleeding (unstable) receiving endoscopy within 2 hrs optimal resuscitation

Percentage admitted with acute upper GI bleeding (stable) receiving endoscopy within 24 hrs optimal admission

Clear pathways and systematised protocols for patient management including transfer

will be developed and agreed by the Trust and commissioners. Adherence to

pathways and protocols will be routinely audited.

October 2014

16

Sentinel Stroke National Audit Programme