Annex 2: Clinical workstream

Annex 2: Clinical workstream

Scarborough ASR | 21 January 2019

2

▪ Clinical workstream timeline

▪ Summary of the clinical case for change

▪ Evaluation criteria

▪ Best practice pathways

▪ Clinical configuration models

▪ Further refinement of clinical models and key questions

Contents

3

The Clinical Reference Group (CRG) has met four times

Discussion agenda

▪ Refine detailed descriptions of clinical models

▪ Review of activity shifts under each clinical model (following discussions with CDs/Deputy CDs and other clinical leads)

▪ Provide update on financial analysis and show preliminary outputs

▪ Refine Case for Change

▪ Explore best practice clinical pathways

▪ Explore potential clinical models for individual service lines

▪ Discuss how these come together into whole hospital clinical models taking into account key clinical interdependencies

▪ Agree long list for more detailed review and analysis

▪ Introduction, objectives and ways of working

▪ Review case for change

– Clinical

– Operational

– Workforce

▪ Discuss proposed evaluation criteria

▪ Look ahead to CRG2

– Best practice pathways

– Clinical models

Outputs

▪ Agree detailed descriptions of clinical models

▪ Finalise Case for Change

▪ Agree long list of clinical models to analyse

▪ Review case for change

▪ Agree high level evaluation criteria

1. Intro and case for change3. Refining descriptions of clinical models

19th September 1st October 24th October

2. Developing service models

4. Detailed review of clinical models

20th November

▪ Detailed discussion of each clinical model

▪ Further shortlisting of potentially viable models for further work

▪ Articulation of key questions that need to be addressed in next phase of work

▪ Selection of clinical models for further work plus key questions to be addressed

PROGRAMME OVERVIEW & GOVERNANCE

4







Contents

5

Summary case for change for Scarborough

… which will result in decreased in-hospital activity…

▪ Currently over 50% of NHS funds available for the local population are spent in the acute sector▪ The clinical evidence base suggests that a greater focus on prevention of ill health and on caring for people with LTCs and frailty in the

community can potentially reduce the need for care within the acute hospital resulting in better health status and greater independence▪ Examples from elsewhere suggest that new models of out of hospital care could reduce the amount of acute activity by ~3.5% per year

… which is good for the local population, but will put further pressure on already fragile, low volume acute hospital services

▪ Scarborough hospital is recognised as a remote site, 42 miles away from the nearest hospital, challenging collaborative working▪ As a result of population size and demographics, acute hospital services in Scarborough have relatively low volumes and acuity, and a relatively

high number of patients who could be treated in a different environment– 51% of attendances at Scarborough A&E (including the UCC) were for minor problems– 73% of all bed days were occupied by patients over 65, compared with 60% nationally– Stranded non-elective patients accounted for 65% of all bed days

▪ Services which need to be provided 24x7 are particularly difficult with relatively small numbers of patients

– Obstetrics sees ~1,400 deliveries per year, the 7th the smallest consultant led obstetric unit nationally

– There were fewer than 3,000 admissions last year to Paediatrics; the national average approaches 5,000

– Only 70% of doctors in training report adequate experience at Scarborough; the national average is 90%▪ 24/7 services are more expensive to run in Scarborough: A&E, women’s services and children’s services costs are 124%, 120% and 128% of

indexed national average assessed costs respectively▪ Staffing of services providing 24x7 care is particularly difficult to provide

– 46% of posts in Emergency and Acute medicine are not filled with a substantive appointment– 26% of consultant workforce is over 55– Locum/agency/bank expenditure at Scarborough Hospital was £10.6 million in 2016/17

… requiring a different sort of care to that historically provided…

▪ Care for people with LTCs and frailty needs to be provided in a different way & in a different place than in the past▪ It will need a more pro-active approach, delivered by multi-disciplinary teams working together, with easier access to diagnostics and specialist

opinion and more consistent quality of care ▪ It will also require greater use of technology, e.g. virtual outpatient clinics or remote monitoring

The local population is ageing and has changing health needs…

▪ Life expectancy is in Scarborough is below the national average for men, driven by high rates of stroke and coronary heart disease▪ The local population (within the catchment) is growing by 0.2% per year but ageing, with the number of people over 70 projected to grow over

the next seven years▪ This will result in a higher prevalence of people with long term conditions (LTCs) and frailty▪ Scarborough has a large and seasonal non-resident population - there are 5 million nights a year spent in the Scarborough region by tourists▪ The underlying population is projected to grow by 2.2% by 2030, in the same period demographic-related activity growth in non-elective care is

projected to increase by 10.4%

The Trust therefore needs to change its model of care to continue providing high quality sustainable services

▪ Building on experiences of similar sized hospitals elsewhere, this is likely to involve:– New forms of collaboration with neighbouring hospitals, in particular York, while remaining cognizant of travel times between the two

sites– More integrated arrangements with local primary and community care services– New workforce models and potentially greater use of technology– Identifying opportunities to utilise the Bridlington site

CASE FOR CHANGE

FULL CASE FOR CHANGE IN ANNEX 2

6

Scarborough’s catchment area

Source: HES 2016/17

10 km

Catchment for Scarborough Hospital1

East Riding of Yorkshire

▪ Bridlington Central and Old Town

▪ Bridlington North

▪ Bridlington South

▪ Driffield and Rural

Ryedale

▪ Cropton

▪ Kirkbymoorside

▪ Pickering East

▪ Pickering West

▪ Rillington

▪ Sherburn

▪ Thornton Dale

▪ Wolds

Scarborough

▪ Castle

▪ Cayton

▪ Central

▪ Derwent Valley

▪ Eastfield

▪ Esk Valley

▪ Falsgrave Park

▪ Filey

▪ Fylingdales

▪ Hertford

▪ Lindhead

▪ Mayfield

▪ Newby

▪ North Bay

▪ Northstead

▪ Ramshill

▪ Scalby, Hackness and Staintondale

▪ Seamer

▪ Stepney

▪ Streonshalh

▪ Weaponness

▪ Whitby West Cliff

▪ Woodlands

Proposed catchment

GP Practice

Hospital

1 Catchment defined by electoral wards where more than 40% of non-elective inpatients were treated at Scarborough Hospital. All GP surgeries in the catchment also met these criteria -no GP surgeries outside of catchment meet this criteria

Electoral wards in Scarborough catchment, by local authority

CASE FOR CHANGE

7Source: ONS 2016-based Sub National Population Projections

Population projection of catchment area

1 Catchment are defined as the following wards: Stepney; Central; Weaponness; Eastfield; Woodlands; North Bay; Newby; Filey; Falsgrave; Northstead; Cayton; Scalby; Hackness and Staintondale; Lindhead; Hertford; Castle, Derwent Valley; Ramshill; Bridlington South; Bridlington North; Seamer; Bridlington Central and Old Town; Thornton Dale; Sherburn; Fylingdales; Pickering East; Streonshalh; Whitby West Cliff; Pickering West; Rillington; Mayfield; Wolds; Cropton; Driffield and Rural; Kirkbymoorside; Esk Valley accessed online in September 2018 [http://www.localhealth.org.uk]

CASE FOR CHANGE

35 36

53 49

53 54

34 39

17832

2018 2025

70-89

90+

50-69

20-49

<20

181+0.2% p.a.

2.0%

0.1%

-1.0%

0.1%

2.2%

2018-25 CAGR, % Population projection by age, area in scope1, ‘000s

2.4

2.3

0.7

-0.2

0.6

All EnglandScarborough

8

Prevalence of chronic diseases in the two local CCGs compared with national average

1 Percentage of age-specific group for Diabetes (ages 17), Depression (18+), Learning Disabilities (ages 18+)

20100 155

Depression (18+)

Hypertension

Chronic kidney disease (18+)

Mental health

Diabetes mellitus (17+)

Asthma

Coronary heart disease

Cancer

Heart failure

Chronic obstructive pulmonary disease

Stroke and transient ischaemic attack

Atrial fibrillation

Epilepsy (18+)

Dementia

Rheumatoid arthritis (16+)

Peripheral arterial disease

Learning disabilities

Palliative care

Osteoporosis (50+)

Scarborough & Ryedale CCG

East Riding of Yorkshire

England Average

Source: QOF 2016/17 - Prevalence, achievements and exceptions at CCG level

Prevalence of diseases – Scarborough & Ryedale CCG, East Riding of Yorkshire CCG and England average,Percentage of population1, 2016/17

CASE FOR CHANGE

9

Emergency hospital admissions

Source: PHE local health tool, accessed online in August 2018 [http://www.localhealth.org.uk]

CASE FOR CHANGE

Hospital admissions, all causes Standardised admissions rate in catchment relative to national average indexed to 100

100

89

104

National average Scarboroughcatchmentemergencyadmissions

Scarboroughcatchmentelectiveadmissions

10SOURCE: Performance and Information Team, York Teaching Hospital NHS Foundation

Trust

Scarborough General Hospital by treatment specialityCASE FOR CHANGE

# of admissions

Inpatient Hospital Admissions per year by treating specialty

# with a procedure carried outTreatment Specialty

Surgical

Medical

Obstetrics/gynae

Paediatrics(0 – 18y.o.)

3,187

2,829

2,670

2,460

2,223

1,230

799

415

198

4,101

3,053

2,930

2,121

1,913

1,548

1,209

548

444

309

205

139

3,222

1,379

784

2,038

1,101

168

General Surgery

Ophthalmology

Colorectal Surgery

Well Babies

Urology

Upper Gastrointestinal Surgery

Trauma & Orthopaedics

Respiratory Medicine

Accident & Emergency

Hepatobiliary & Pancreatic Surgery

Other

Obstetrics

Cardiology

Medical Oncology

Gastroenterology

Geriatric Medicine

Gynaecology

Endocrinology

Clinical Haematology

Nephrology

General Medicine

Rheumatology

Diabetic Medicine

Other

Midwife Episode

Paediatrics

Neonatology

2,905

2,829

2,513

2,460

1,227

1,053

569

415

181

1,420

1,633

2,838

1,102

908

797

1,194

359

373

303

22

113

1,295

696

281

163

78

6

11

Maternity and paediatric attendances compared with local peers and those serving similar populations

SOURCE: HES 2016/17

Average

1 Excluding sites with <100 births per year. Defined by relevant HRG codes for births 2 Emergency admissions for infants and children under 19

CASE FOR CHANGE

10

0

2

8

4

6

3.2

0

5

10

15

30

4.7

James Cook

Scarborough

Hull

York

Hereford County

Pilgrim

West Cumberland

Hereford West Cumberland

YorkScarborough

Hull

JamesCook

Pilgrim

Emergency pediatric spells2

Maternity deliveries1

Activity level by site across England 16/17, ‘000s

12

Patients attending Scarborough A&E who live outside of local area by month

8.2 7.7

9.2 9.6

13.8

9.2

6.8

4.5 4.6

2.93.7

5.0

NovApr2017

May JulJun Aug OctSep Mar2018

Dec Jan Feb

Percentage of patients attending Scarborough A&E who live outside of local area1

% of all A&E attendances (Apr 2017-Mar 2018)

SOURCE: Performance and Information team, York Teaching Hospitals NHS Foundation Trust

1 Local area defined as the following CCGS: East Riding of Yorkshire, Harrogate and rural district CCG, Hambleton Richmondshire and Whitby CCG, Scarborough & Ryedale CCG, Vale of York CCG, Wakefield CCG

CASE FOR CHANGE

13

A&E attendances to Scarborough A&E by severity

50

1,152

1,495

8,235

1,820

930

4,834

8,220

8,464

19,725

VB07Z - Cat 2 Ix with Cat 2 Rx

VB01Z - Cat 5 Rx




VB03Z - Cat 3 Ix with Cat 1-3 Rx


VB10Z – Emergency dental



VB11Z - No sig Ix or Rx

1

All attendances1

A&E attendances (‘000), 2016/17

54,928Total2

Major

Normal

Minor

20%

29%

51%

CASE FOR CHANGE

1 Includes Type 1 (regular ED) and Type 3 (GP led UCC) attendances 2 VB99Z excluded (Dead on arrival- 2 patients both attending Type 1 A&E)

SOURCE: Performance & Information Team, York Teaching Hospital NHS Foundation Trust

50

1,152

1,491

8,234

1,820

903

4,793

7,790

4,359

1,300

1

Attendances to Type 1 A&E only

34%

48%

18%

31,895

14

Attendances at all A&E types for local CCGs compared with peers

SOURCE: HES 2016/17 M13 A&E, c/o NHS Digital

1 Peer group defined as the 10 CCGs most similar to Scarborough and Ryedale by NHS Right Care (Hastings and Rother, Great Yarmouth and Waveney, West Norfolk, South Kent Coast, Isle of Wight, Lincolnshire East, Hereford, Airedale, Wharfedale and Craven, Lincolnshire West, and Harrogate and Rural District)

CASE FOR CHANGE

527.3376.4 325.1 266.4

360.0 296.5

133.7160.8 170.1 158.2 174.8 156.4

392.7

204.2151.7 107.2

172.8 121.9

A&E attendances at all A&E Types per 1,000 weighted population

Total A&E attendances

Minor A&E attendances

Major/ normal A&E attendances

East Riding of Yorkshire CCG

Peer group average

Peer group top quartile

England average


England top quartile

CCG performanceabove England average

CCG performance at, orbelow, England average

15

Attendances to type 1 A&Es for local CCGs compared with peers

SOURCE: HES 2016/17 M13 A&E, C/o NHS Digital

1 Peer group defined as the 10 CCGs most similar to Scarborough and Ryedale by NHS Right Care (Hastings and Rother, Great Yarmouth and Waveney, West Norfolk, South Kent Coast, Isle of Wight, Lincolnshire East, Hereford, Airedale, Wharfedale and Craven, Lincolnshire West and Harrogate and Rural District)

CASE FOR CHANGE

289.7182.0

252.7 237.7 276.6 234.1

132.2 117.2158.0 149.6 162.7 144.0

157.5

64.8 93.3 84.2 113.3 83.5

A&E attendances at all A&E Types per 1,000 weighted population

Total A&E attendances

Minor A&E attendances

Major/ normal A&E attendances

East Riding of Yorkshire CCG

Peer group average

Peer group top quartile

England average


England top quartile

CCG performanceabove England average

CCG performance at, orbelow, England average

16

Bed days for people over 65 years compared with local peers and hospitals of similar size and remoteness

Hospital bed days in over 65s as a percentage of all bed days

SOURCE: HES 2016/17 APC M13, c/o NHS Digital

73

70

58

56

72

70

69

60

27

30

42

44

28

30

31

40

121

Hull

Scarborough

West Cumberland

100% =

York

England

James Cook

Pilgrim

Hereford

<6565+

228

272

307

120

134

61

38,059

Local peers

Peers serving similar populations

CASE FOR CHANGE

2016/17, % (total in ‘000s)

17

65% of bed days at Scarborough hospital are occupied by stranded patients with length of stay 8 days or longer (majority aged over 65)

1 Excluding RA (regular attenders) and Other (not recorded type), Paediatrics patients are defined by age 0 – 18 years old; 2 Figures calculated assuming that all patients in this category currently stay for 31 days, will go down to trust average LOS for NEL patients, and each reduction of a 20 bed unit saves a hospital £2 million

SOURCE: HES 2016/17

8%

10

Other non-elective

32%

4%

Maternity

17%

18%

2%

3

Non-elective aged 65+

0

Elective

9%

Paeds

2%

1%

6%

2%

131 1

100%= (in ‘000s) = 46,000

bed days

8-30 days

Patients with LOS of 0-7 days and days 0-7 of patients with LOS >7 days

31+ days2016/17 bed days by LOS band and POD1

Total bed days and % of POD

CASE FOR CHANGE

18

18 week RTT performance for local CCGs

95

85

93

83

82

88

84

97

86

89

87

90

91

92

96

94

Q2Q4 Q3

2013-2014, Q1 Q3Q2 Q3 Q4

2014-2015, Q1

2015-2016, Q1Q2 Q3 Q4

2016-2017, Q1

92

Q2

East Riding of Yorkshire CCG National top quartileScarborough & Ryedale CCG National average

SOURCE: HSJ Intelligence 2018

CASE FOR CHANGE

RTT performance against 18 week target, %

19

Costs related to smallness and remoteness

Peer group2National average

Scarborough

100110

120

Total service costs1 as percentage of national average (adjusted for MFF2) FY14/15%

1 Includes costs for Critical Care, Outpatients, Elective IP, Non-elective IP, Daycase and A&E 2 MFF is market forces factor 3 Peer group considered: St Mary's Isle of Wight. West Cumberland, Cumberland Infirmary, North Devon NHS Trust

SOURCE: York Teaching Hospital NHS Trust Analysis, Benchmarking unavoidable smallness - Benchmarking and review of costs at Scarborough and Bridlington sites' 2016

100111

124

National average

Peer group2 Scarborough

A&E assessed costs as percentage of national average (adjusted for MFF), FY14/15%

100

125 120

National average

Peer group3 Scarborough2

Maternity services costs as percentage of national average (adjusted for MFF), FY14/15%

100

126 128

National average

Peer group3 Scarborough2

Children’s services costs as percentage of national average (adjusted for MFF), FY2014/15%

CASE FOR CHANGE

20

Locum spend at Scarborough and York

2%(0.2)

34%(3.1)

39%(4.2)

33%(3.5)

2%(0.2)

11%(1.2)

15%(1.6)

Scarborough1

15%(1.4)

44%(4.0)

6%(0.5)

York

Consultant

Medical staff grade

Medical trainee

Nursing

Other

Expenditure on locum or agency staff by group, FY2017/18% (£ million)

1 Includes locum/agency spend at Bridlington

SOURCE: Expenditure team, York Teaching Hospitals NHS Foundation Trust

10.7 9.7Total locum spend(£million)

CASE FOR CHANGE

21

Agency, bank and locum spend

7%(0.2)

Q4

70%(2.4)

4%(0.1)

10%(0.3)

6%(0.2) 21%

(0.8)23%(0.8)

Q2 Q1 2018/19

29%(1.1)

16%(0.6)

73%(2.6)

4%(0.2)

Q3

78%(2.5)

18%(0.6)

62%(2.2)

4%(0.1)

Q4

75%(2.2)

22%(0.6)

27%(1.0)

68%(2.0)

3%(0.1)

11%(0.4)

Q1 2016/17

74%(2.3)

6%(0.2)

22%(0.7)

6%(0.2)

4%(0.1)

Q2

20%(0.7)

7%(0.2)

Q3

79%(2.8)

78%(2.7)

25%(0.9)

Q1 2017/18

73%(2.8)

Q2

22%(0.7)

10%(0.3)

73%(2.6) 62%

(2.3)

10%(0.4)

Q4

Average quarterly

spend £3.4 million

Q1 2015/16

84%(2.7)

16%(0.5)

Q3

LocumAgency Bank

3.5 3.3 3.5 3.2 2.9 3.1 3.5 3.6 3.5 3.9 3.0 3.7 3.6

xx Total spend£million

Agency, bank and locum spend at Scarborough Hospital 2015/16-2018/19

% (£ million)

SOURCE: Finance team, York Teaching Hospital NHS Foundation Trust

Total spend=

CASE FOR CHANGE

22

Consultant vacancies at Scarborough Hospital

83%(15)

Ort

ho

pae

dic

s

Spec

ialis

t m

edic

ine

67%(4)

Paed

iatr

ics

17%(3)

100%(8)

6

29%(4)

Wo

men

’s

98%(8)

100%(3)

Eme

rgen

cy &

Acu

te m

edic

ine

An

aest

het

ics

& C

riti

cal c

are

69%(9)

77%(5)

23%(1)

18

Eld

erly

med

icin

e

71%(9)

31%(4)

Gen

era

l su

rger

y&

Uro

logy

33%(2)

Rad

iolo

gy

58%(9)

42%(7)

Gen

eral

m

edic

ine

54%(4)

46%(3)

50%%(2)

50%(2)

413

Op

thal

mo

logy

Budgeted FTE=

8 3 8 6 12 16 7

Filled posts Vacant postsCurrent consultant establishment in ScarboroughPercentage of vacant and filled FTEs as at end of July 2018

SOURCE: Human Resources Team, York Teaching Hospitals NHS Foundation Trust; discussion between HR team and directorate managers

% (No. of FTEs)

CASE FOR CHANGE

23

Vacancies for non-consultant grade doctors at Scarborough Hospital

113%(14)

Wo

men

’s h

ealt

h

-13%(-2)

90%(11)

5%(1)

95%(19)

Paed

iatr

ics

97%(2)

Rad

iolo

gy

100%(1)

3%(0)

Spec

ialis

t M

edic

ine

Gen

eral

Su

rger

y &

Uro

logy

92%(11)

8%(1)

Ort

ho

pae

dic

s68%(10)

32%(5)

Eld

erly

Med

icin

e

Eme

rgen

cy &

A

cute

Med

icin

e

62%(30)

38%(19)

Gen

eral

Med

icin

e

60%(3)

40%(2)

49

Op

thal

mo

logy

60%(9)

40%(6)

An

aest

het

ics

& C

riti

cal C

are

35%(4)

65%(7)

Budgeted FTE= 10%

(1)

2 20 12 12

12

10155 115

Filled posts Vacant posts

SOURCE: Human Resources Team, York Teaching Hospitals NHS Foundation Trust

1 Includes Doctors in Training and Non-consultant Grade Doctors

Current non-consultant establishment1 in ScarboroughPercentage of vacant and filled FTEs as at end of July 2018

% (Number of FTEs)

CASE FOR CHANGE

24

Percentage of consultants at Scarborough Hospital who are 55 or more years old

50%(2)

All

con

sult

ant

po

sts

8

50%(2)

Ort

ho

pae

dic

s

Gen

eral

su

rger

y&

Uro

logy

74%(54)

26%(19)

An

aest

het

ics

&C

riti

cal

care

100%(2)

Op

hth

alm

olo

gy

Rad

iolo

gy

8

Eme

rgen

cy &

A

cute

med

icin

e

50%(2)

50%(2)

66%(6)

34%(3)

30%(3)

Gen

eral

med

icin

e

70%(7)

75%(6)

9

25%(2)

2

80%(6)

20%(2)

Wo

men

’s

83%(3)

17%(1)

Eld

erly

med

icin

e

86%(13)

14%(2)

87%(7)

4

13%(1)

Paed

iatr

ics

4

100%(2)

73

Spec

ialis

tm

edic

ine

Budgeted FTE = 4 10 8 15 2

Less than 55 55 or more

SOURCE: Human Resources Team, York Teaching Hospitals NHS Trust

Percentage of current workforce aged 55 years or overConsultants as at end of June 2018

% (Number of FTEs)

CASE FOR CHANGE

25







Contents

26

Evaluation criteria: overview EVALUATION CRITERIA

Focus of the evaluation by the clinical reference group

Defined asEvaluation criteria

1.1 Clinical effectiveness

1.2 Patient and carer experience

1.3 Safety

Quality of Care1

2.1 Impact on patient choice

2.2 Distance, cost and time to access services

2.3 Service operating hours

2.4 Ability for clinicians to access specialist input

Access to care2

3.1 Scale of impact

3.2 Impact on recruitment, retention, skills

3.3 Sustainability

Workforce3

4.1 Forecast income and expenditure at system and organisation level

4.2 Capital cost to the system

4.3 Transition costs required

4.4 Net present value (30 years)

Value for money4

5.1 Expected time to deliver

5.2 Co-dependencies with other strategies/strategic fit

Deliverability5

27

Proposed sub-criteria: Quality of care

Questions to test

Clinical effectiveness

▪ Does this model enable the population of Scarborough and surrounding areas to receive acute services in line with national standards and other recognised best practices?

▪ Will this model allow sufficient volumes of cases to sustain quality?

▪ Will this model result in more effective prevention in order to improve life expectancy in the system and reduce health inequalities?

▪ Will this model account for future changes in the population size and demographics?

▪ Will this model lead to more people being treated by teams with the right skills and experience?

Patient and carer experience

▪ Will this model improve continuity of care for patients? (e.g., reduce number of hand offs across teams / organisations, increase frequency of single clinician / team being responsibility for a patient)?

▪ Will this model enable greater opportunity to link with voluntary / community sector health and wellbeing services?

▪ Will this model improve quality of environment in which care is provided?

▪ Will this model allow for patient transfers/emergency intervention within a clinically safe time-frame? Will travel time impact on patient outcome?

▪ Will this model offer reduced levels of risk (e.g., staffed 24/7 rotas, provide networked care, implement standardisation)?

Patient safety

Evaluation criteria

1EVALUATION CRITERIA

28

Proposed sub-criteria: Access to care

Impact on patient choice

▪ Will this model increase or decrease choice for patients?

▪ Will this model make it easier for people to understand which services they can access when and where?

Distance, cost and time to access services

▪ Will this model increase/reduce travel time and/or cost for patients to access specific services?

▪ Will this model involve patients travelling more/less frequently, change the number of journeys to access urgent medical intervention?

▪ Will this model reduce/increase patients' waiting time to access services?

▪ Will this model increase/reduce travel time and/or cost for carers and family?

▪ Will this model support the use of new technology to improve access?

▪ Will this model improve operating hours in line with demands of the population?

▪ Will this model reduce the risk of unplanned changes and improve service resilience?Service operating hours

Questions to test

▪ Will this model increase or decrease the time to access specialist input?Ability for clinicians to access specialist input

Evaluation criteria

EVALUATION CRITERIA

2

29

Proposed sub-criteria: Workforce

Scale of impact▪ What proportion of current staff will be impacted by the changes across the

system?

Impact on recruitment, retention, skills

▪ Will this model improve the recruitment and retention of permanent staff with the right skills, values and competencies?

▪ Is the staff travel, relocation or retraining required for this option acceptable?

▪ Is it possible to develop the skills base required in an acceptable time frame?

▪ Will this model enable accountability and governance structures to support staff?

▪ Will this model increase multi-disciplinary / cross-organisational working?

▪ Is this model likely to improve or maintain job satisfaction?

Questions to test

Sustainability

▪ Will this model enable staff to maintain or enhance competencies? (e.g., impact on volumes of activity / specialism; increased training / opportunity for accreditation and career progression)

▪ Will this model optimise the use of clinical staff and enable them to work at the “top of their license” versus being spread thinly?

Evaluation criteria

EVALUATION CRITERIA

3

30







Contents

31

The CRG has developed and refined best practice pathways in four areas

▪ Elective care pathway2

▪ Maternity and paediatric pathway3

▪ Urgent and emergency care pathway

1

▪ People with long term conditions (LTCs) and frailty

4

BEST PRACTICE CARE PATHWAYS

32

▪ Patients can access information rapidly to guide them to the appropriate level of care based on the severity of their illness

▪ Interaction with overlapping pathways (e.g. frailty and mental health) to guide patients to most appropriate care

▪ Patients have easy access (local, short travel, easy parking, etc.); Wait times are reasonable and communicated accurately

▪ Should be able to have easy access in extended hours

▪ Investigation given right away at point of contact or same day, as close to 1st contact as possible (e.g. one-stop ambulatory care if possible)

▪ Real-time tests are used to help inform decision

▪ Minimum amount of investigations at appropriate time required to provide an accurate diagnosis

▪ Onsite or remote support, including reporting as required

▪ Consistent investigations with same standards in all locations

▪ Focus on completing diagnosis to rule out major illness/injury vs minor problems

▪ Clear and easy route to escalation if indicated by investigation or examination

▪ Timely, appropriate care▪ Good communication that gives

patient understanding of the problem, including potential complications

▪ Patient is discharged as quickly as possible

▪ Patients given good advice and simple explanations of next steps for recovery

▪ Any follow-up is as convenient as possible for the patient (e.g., virtual/remote, local)

▪ If complications arise, patients have clear pathway and can follow it easily and quickly

Minor illness (e.g., urinary symp-toms)

▪ Timely, appropriate care in a single encounter

▪ Good communication that gives patient understanding of the problem, including potential complications

▪ Patient is discharged as quickly as possible

▪ Patients given understanding of follow-up required (best case: no follow-up)

▪ Follow-up (when required) is easy to schedule and conveniently located for patient

▪ If complications arise, patients have clear pathway and can follow it easily and quickly

▪ Patients can publicly access information rapidly to guide them to the appropriate level of care based on the severity of their injury (e.g. 111, pharmacies)

▪ Patients are able to access a convenient location nearby where they can be seen relatively quickly / are clearly communicated as to what the timing will be

▪ Low level diagnostics (incl. X-rays) as required - only relevant tests completed

▪ Simple, quick, focused investigation, where the results are explained quickly and easily understandable

▪ Onsite or remote support, including reporting as required

▪ Clear and easy route to escalate into major injury category if indicated by investigation or examination

Minor Injuries (e.g., laceration requiring stitches)

Triage and first contact with healthcare professional

Investigations Treatment Follow-up


Urgent and emergency care pathway: ‘minor’ patients REVISED PATHWAY1

33

Urgent and emergency care pathway: ‘major’ patients

▪ Patient has immediate access to assessment at correct place of treatment, the appropriate clinician (e.g. correct skills) is available to provide an accurate diagnosis

▪ Assessment by (consultant) within 12 hours

▪ Explanations are simple, advice is clear, next steps are described, easy access for patients to ask questions

▪ Sufficient diagnostic facilities to allow initial triage for >90% of patients to correct transfer location

▪ Full range of assessments available as required, quickly

▪ Rapid access to specialist opinion within appropriate timescale

▪ On site 24/7 care available▪ Care given in one place, as quickly

as necessary▪ Care provided by specialist where

appropriate▪ All types of assessments required

given (e.g., scans, blood, etc.), as regularly as required

▪ Access to ICU if required▪ Access to medical or surgical

opinion and surgery if necessary

▪ Discharged as soon as possible▪ Follow up is provided to patients

with part of their care team or another specialist, as conveniently as possible for the patient

▪ Re-entry into appropriate pathways supported should issues arise

Standard/major Illness (e.g., chest pain and fever)

First contact with healthcare professional

Investigations Treatment Follow-up

Moderate trauma (e.g. #NOF)

▪ On site 24/7 care available▪ Treatment in line with national

standards e.g. for #NOF▪ Clinicians with relevant training

available▪ Enhanced recovery + rehab (e.g.

PT / OT) given as required▪ Discharged as quickly as possible▪ Clear and speedy escalation

pathway if necessary

▪ Follow-up with member of patient treatment team as local as possible

▪ Patients able to recover as close to home as possible / at home if possible


▪ Patient seen in appropriate centreas local as possible

▪ Support from relevant specialty available within acceptable timeframe at the location or remotely where appropriate

▪ Support services available as required

▪ Additional assessments given as required (X rays, CT, etc.)

▪ Diagnosis made quickly on one site or remotely and communicated clearly, with treatment options provided / explained

▪ Patient is taken to agreed major trauma centre to ensure quality of care

▪ Support available immediately at the location

▪ Treatment ideally given at only one place

▪ Full range of complex support services available as required

▪ Additional assessments given as required (X rays, CT, etc.)

▪ Diagnosis made quickly on one site and communicated clearly, with treatment options provided / explained

▪ Specialists available within appropriate timeframe

▪ On site 24/7 care available▪ Clinicians with adequate relevant

training in issue available▪ Enhanced recovery and access to

other specialists given as required▪ Access to ICU if required▪ Discharged as quickly as possible

▪ Follow up available with member of patient treatment team as local as possible

▪ Patients able to recover as close to home as possible / at home if possible


Major complex condition or Trauma (e.g., major RTA)


REVISED PATHWAY1

34

Urgent and emergency care pathway: clinical standards and best practice evidence

First contact with healthcare professional Investigations Treatment Follow-up

‘Minor’ patients

▪ Integrated primary care to reduce avoidable emergency admissions (GMS Contract, 2014/15)

▪ Every emergency department should have a co-located primary care out-of-hours facility (Acute and emergency care: prescribing the remedy, 2014)

▪ Treatment at scene (or transfer to primary/community care) where appropriate (Transforming NHS Ambulance Services, NAO, 2011)

▪ Each emergency department and acute admissions unit has an IT infrastructure that effectively integrates clinical and safeguarding information across all parts of the urgent and emergency care system (Seven Day Clinical Standards, NHS England, 2014)

▪ Community and social care must be coordinated effectively and delivered 7 days a week to support urgent and emergency care services (Acute and emergency care: prescribing the remedy, 2014)

▪ All hospitals admitting medical and surgical emergencies should have access to all key diagnostic services (e.g., diagnostic imaging, interventional radiology, interventional endoscopy, bronchoscopy, pathology) in a timely manner 24 hours a day, 7 days a week, to support decision making (The Royal College of Emergency Medicine, Emergency Department Capacity Management Guidance, 2015)

▪ Critical Care Unit should have dedicated medical cover present in the facility 24 hours per day, 7 days per week (NHS Services, Seven Days a week, 2013)

▪ Radiological services, including ultrasound and CT scanning, should be available 7-days per week to aid sepsis diagnosis and potentially drain infected collections. If applicable, source control (percutaneous drainage/surgery) should be undertaken as soon as practically possible and within 12 hours. (Guidelines for Provision of Intensive Care Services, 2016)

▪ Triage, treatment and discharge or admission within 4 hours (national standard)

▪ Senior decision-makers at the front door of the hospital, and in surgical, medical or paediatric assessment units, should be normal practice, not the exception (CEM, Workforce Recommendations, 2010; and The Way Ahead 2008-2012, 2008)

▪ Any surgery conducted at night should meet NCEPOD requirements and be under the direct supervision of a consultant surgeon (NHS London, Adult emergency services: Acute medicine and emergency general surgery commissioning standards, 2011)

▪ Provide consultant-delivered emergency general surgery in each trust (GIRFT general surgery report, 2017)

▪ Acute medicine inpatients should be reviewed daily be a relevant consultant (Transforming urgent and emergency care services in England, 2015)

▪ There must be rapid 24/7 availability of a doctor with advanced airway and resuscitation skills (Guidelines for Provision of Intensive Care Services, 2016)

▪ Admission to Intensive Care must occur within 4 hours of making the decision to admit (Guidelines for Provision of Intensive Care Services, 2016)

▪ Units must not utilise greater than 20% of registered nurses from bank/agency on any one shift when they are NOT their own staff. (Guidelines for Provision of Intensive Care Services, 2016)

▪ When on-take for emergency / acute medicine and surgery, a consultant and their team are to be completely freed from any other clinical duties / elective commitments that would prevent them from being immediately available (Transforming urgent and emergency care services, 2015)

▪ All emergency admissions to be seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital ( Transforming urgent and emergency care services in England, 2015)

▪ Prompt screening of all complex needs inpatients should take place by a multi-professional team which has access to pharmacy, psychiatric liaison services and therapy services (including physiotherapy and occupational therapy, 7 days a week with an overnight rota for respiratory physiotherapy) (NHS England , Commissioning Standards Integrated Urgent care, 2015)

▪ Where available resources mandate a combined rota with ICM and non-ICM consultant staff, to ensure the provision of an appropriate adult critical care service, there should be:

– Dedicated daytime consultant ICM cover 7 days per week

– Availability of advice from intensivists where needed

(Interim guidance on governance for smaller remote and smaller rural Intensive Care units, ICS, 2018)

Standard/ major Illness (e.g., chest pain and fever)


REVISED PATHWAY1

35

Elective care pathway: low complexity

▪ Initial investigations done at point of first contact or as quickly as possible / close to patient as possible

▪ All investigations required are provided quickly and closely (e.g., pathology / imaging/endoscopy)

▪ Early communication of results & immediate referral of urgent problems (as per protocol)

▪ One clinical information system for use

▪ Day surgery when possible

▪ No cancellations

▪ All appropriate equipment available for the procedure

▪ All pre-op assessment standardised, carried out at initial decision to treat and carried out locally

▪ Seamless package of care

▪ Procedures to be provided locally

▪ Surgeons and teams are provided adequate volumes & avoid duplication of services

▪ Appropriate level of in hours cover

▪ High calibre out of hours cover

▪ Services ensure quality patient experience & satisfaction

▪ Continued provision of an appropriate training environment

▪ Early decision confirming patient suitable for local treatment

▪ Robust rescue plan and escalation policy for the deteriorating patient including access to HDU or ICU either locally or within network

▪ Delivery of upper quartile outcomes standardised mortality

▪ Openness and clear communication to patient on what is being provided

▪ One clinical information system

▪ Clear patient ownership during inpatient stay

▪ Full use of processes to enable early discharge

▪ All to be provided locally including out of hospital

▪ Clear protocols for post operative management

▪ Follow ups minimised and only as required

▪ High-quality electronic discharge summary

▪ Access is standardised across populations, with minimal delays and referrals prioritised based on patient problems. Patients are triaged as required depending on urgency of condition

▪ No patient is not provided access

▪ Clear to patients who they should be seeing and why (e.g., referral from GP)

▪ Wait times are in line with or better than national targets including for 2 week rule referrals and patients suspected of cancer


▪ High-quality advice and guidance provided to inform patients of choice and next steps

▪ Technology leveraged to facilitate process (e.g., electronic communication) with rapid communication back to referrer


▪ Care is provided across specialties as much as possible with provision of elective outpatient care aligned with need for specialist presence in acute hospital to cover urgent and emergency care

▪ Care completed as locally as possible

▪ Access is standardised across populations

▪ Wait times are less than 7 days

▪ Local referral protocols standardised & followed

▪ Consistent, standardised advice and guidance process (on things like local policy) using up-to-date technology to ensure one seamless pathway


▪ Clear communication to patient on what is being provided

▪ Direct access to intervention through multiple providers (e.g., physio)

▪ Direct access to investigation

Primary careFirst acute contact with healthcare professional

Investigations Interventions Follow-up

Majority of planned care occurs in primary care


REVISED PATHWAY2

36

Elective care pathway: high complexity

▪ As in Low Complexity

▪ Interventional treatment done locally when possible but may need to be referred to specialist centrefor low volume complex procedures in high risk patients

▪ As in Low Complexity

▪ All preop assessment standardised, carried out at initial decision to treat and carried out locally wherever possible

▪ Early decision confirming if patient suitable for local treatment or if patient unsuitable for local treatment and has to be transferred to another centre

▪ As many procedures as possible to be provided locally

▪ Surgeons and teams are provided adequate volumes

▪ Robust out of hours cover aligned with the complexity of the procedure and the comorbidities of the patient

▪ Robust rescue plan and escalation policy for the deteriorating patient including access to HDU or ICU either locally or within network

▪ Seamless package of care irrespective of location of that care

▪ Minimum length of stay if patient transferred to another centre for treatment with consideration of transfer back to local centrefor post operative care if appropriate

▪ Full use of processes to enable early discharge both locally and when care provided in other centres

▪ As much as possible to be provided locally irrespective of location of surgery

▪ Clear protocols for post operative management

▪ Follow ups minimised and only as required

▪ High quality electronic discharge summary with clear guidelines for the management of complications

▪ Access is standardised across populations, with minimal delays and referrals prioritised based on patient problems. Patients are triaged as required depending on urgency of condition

▪ No patient is not provided access

▪ Clear to patients who they should be seeing and why (e.g., referral from GP)

▪ Wait times are in line with or better than national targets including for 2 week rule referrals and patients suspected of cancer


▪ High quality advice and guidance provided to inform patients of choice and next steps

▪ Technology leveraged to facilitate process (e.g., electronic communication) with rapid communication back to referrer


▪ Care is provided across specialties as much as possible with provision of elective outpatient care aligned with need for specialist presence in acute hospital to cover urgent and emergency care

▪ Care completed as locally as possible

▪ Access is standardised across populations

▪ Wait times are less than 7 days

▪ Local referral protocols standardised & followed

▪ Consistent, standardised advice and guidance process (on things like local policy) using up to date technology to ensure one seamless pathway


▪ Clear communication to patient on what is being provided

▪ Direct access to intervention through multiple providers (e.g., physio)

▪ Direct access to investigation

Majority of planned care occurs in primary care


Investigations Interventions Follow-up


REVISED PATHWAY2

37

Elective care pathway: clinical standards and best practice evidence

▪ Require reversible risk factors to be addressed prior to non-urgent procedures, using a patient-centredapproach utilizing shared decision-making (GIRFT general surgery report, 2017)

▪ Patients should be admitted in ring-fenced beds, on the day of surgery where possible (RCSI Model of Care for Elective Surgery, 2013)

▪ Enhanced recovery and discharge planning should begin at the outset of the patient’s elective surgical journey (RCSI Model of Care for Elective Surgery, 2013)

▪ Ensure that every patient is reviewed by a consultant surgeon, seven days a week (RCS Good surgical practice 2014

▪ When complexity is an issue as appropriate, patients should be transferred to another unit where resources and skills are available (RCS Good surgical practice, 2018)

▪ Ensure that diagnostic and therapeutic interventions can be undertaken in the right setting including one-stop outpatient facilities to minimise disruption to patients whilst enabling effective use of resources (RCS Outpatients clinics: a guide to good practice, 2017)

▪ Community rehabilitation services should be adequately resourced to provide early, intense and frequent rehabilitation to all hip fracture patients (British Orthopaedic Association, A national review of adult elective orthopaedic services in England, 2015)

▪ Radiology, laboratory and other tests are performed as expeditiously as possible, necessitating a minimum number of hospital visits for the patient. Hospital outpatient clinics should be coordinated where possible (RCSI Model of Care for Elective Surgery, 2013)

▪ Ensure all units are operating within a hub and spoke network model, as defined by the national service specification, emulating the most advanced hub and spoke models that exist currently. This in turn should deliver improved early decision-making capability and access to diagnostics, allowing early treatment, prioritised by degree of urgency (GIRFT Vascular Surgery report, 2018)


Investigations Admission for surgery Follow-up


REVISED PATHWAY2

38

Paediatrics: best practice care for acutely unwell child

▪ Easy access to information to support parental decision making – on phone/online/ applications

▪ Parental education through health visitors and other parental groups

▪ Parents have easy access (local, short travel, easy parking, etc.); Wait times are reasonable and communicated accurately

▪ Should be able to have easy access –same day and extended hours

▪ Standardised screening tests and protocol

▪ Parent able to obtain same day appointment in out of hospital setting

▪ Suitably qualified staff e.g. GP/nurse with experience in paediatrics

▪ Access to paediatric expertise in person (e.g. MDT or specialist clinics in primary care) or over the phone/online (e.g. specialist number, via e-referral system) to allow speedy and appropriate escalation

▪ Treatment as per protocols

▪ Shared records with parents and inpatient/referral unit

Unwell child

Immediate assessment and treatment

Treatment Follow-up TreatmentTriage and first contact Follow-up

▪ Direct referral to hospital as per standardisedprotocols

▪ Paediatric expertise (nurse, consultants, middle grade, ANP) available on site during opening hours

▪ If <1 year, child should be seen by consultant paediatrician

▪ Safeguarding expertise available if required

If admitting:▪ Direct transport to IP

unit, with barrier free transfer

▪ Quick referral systems, uninterrupted, no ability to refuse or delay a referral

▪ Shared staffing with ED

▪ Shared records through online secure system

If observing:▪ Assessment unit

should have a minimum of 2 registered children’s nurses at all times

▪ Wards should have extended opening hours

If discharging: ▪ Follow up phone call

next day for those discharged from SSAU

▪ Shortest stay possible in IP unit

▪ Early discharge with monitoring in community

▪ 7 day community services to enable early discharge

▪ 1:4 nursing ▪ Consultant presence

24x7 (10 WTE paediatric consultants)

▪ Follow up done in community with access to specialists in clinic next day as required (SSPAU or community access)

▪ Consultant to follow up if needed or community nurses or GP to be done in home, hospital, or GP practice

▪ Assessment unit (SSPAU) has ambulatory care and follow ups


REVISED PATHWAY3

39

Paediatrics: clinical standards and best practice evidence for care of the acutely unwell child

Unwell child: Clinical standards and best practice evidence

Immediate assessment and treatment Treatment Follow-up TreatmentTriage and first contact

▪ Whole pathway commissioning for children’s services that includes ED attendance or hospital admission avoidance by easy availability of GP urgent appointments and consultant led provision of rapid access paediatric clinics (Joint Statement by RCGP, RCN, RCPCH and CEM on the urgent & emergency care of children and young people, 2011)

▪ Hours of operation for Short Stay Paediatric Assessment Units (SSPAU) should match times of population demand (RCPCH, Standards for SSPAU, 2017)

▪ Alternatives to full hospital admission by provision of SSPAUs (with the same role as Clinical Decision Units for adults) run in partnership with Emergency Departments, as well as early discharge enablement by community nursing and SSPAUs (Joint Statement by RCGP, RCN, RCPCH and CEM on the urgent & emergency care of children and young people, 2011)

▪ Every child or young person on the SSPAU with an acute medical problem is seen by appropriate tier-two specialist within 4 hours and consultant* within 14 hours (RCPCH, Standards for SSPAU, 2017)

▪ Contracted staffing levels and competencies for children trained clinicians (including safeguarding) must reflect the standards set by RCPCH, RCN, CEM

▪ Health professionals should have access to the child’s shared record (RCPCH, Standards for SSPAU, 2017)

▪ Effective safeguarding systems are child centred (Working Together to Safeguard Children, 2013)

▪ Evidence-based guidelines are used for the management of conditions with which infants, children and young people may be admitted to the SSPAU (RCPCH, Standards for SSPAU 2017)

▪ A consultant paediatrician* is readily available on the hospital site at times of peak activity of the SSPAU and is able to attend at all times within 30 minutes. Throughout all the hours they are open, SSPAUs have access to the opinion of a consultant paediatrician* via telephone (RCPCH, Standards for SSPAU 2017)

▪ All paediatric inpatient units adopt an “attending consultant” system

▪ All general acute paediatric consultant rotas are made up of ≥10 EWTD-compliant WTEs

▪ There should be a minimum of two registered children’s nurses at all times in all inpatient and day care areas

▪ Specialist paediatricians are available for immediate telephone advice for acute problems for all specialties and paediatricians (RCPCH Facing the Future, 2015)

▪ Before they are discharged, every child referred for a paediatric opinion is seen by, or has their case discussed with: a consultant paediatrician, a middle grade paediatrician, or an advanced children’s nurse practitioner (RCPCH Standards for Paediatric Services, 2015)

▪ Children and young people and their parents and carers are provided, at the time of their discharge, with both verbal and written discharge and safety netting information, in a form that is accessible and that they understand (RCPCH, Standards for SSPAU, 2017)

* Or equivalent


REVISED PATHWAY3

40

Maternity pathway: best practice summary

Pre-conception(in community)

Antenatal care BirthPost-natal & neonatal care

▪ Implement integrated programme of women’s health (including smoking cessation), sex education and contraception through primary care, community and schools (supported by council)

▪ Provide pre-conception advice and counselling for prospective parents on complicating factors in pregnancy

▪ Primary care ensures at risk women (social and clinical) are offered pre pregnancy advice e.g. for women with epilepsy or diabetes

▪ Booking referral by midwife by 10 weeks (National guidance)

▪ Rigorous ongoing risk assessment– Stratify patients by risk– Midwifery groups

responsibility for identifying high risk women and targeting services at them

▪ Adopt NICE guidance– 7-10 antenatal

appointments– 2 ultrasounds in low risk

pregnancy– Include all national

screening programmes in routine care

▪ Adopt midwife led care model (case loading), with direct access to midwives; access to OUs as needed

▪ Concentrate services in easy-access local community centresto facilitate registry and productivity

▪ Leverage IT-enabled solutions to increase sharing of records and improve productivity in community-based care

▪ Use MSWs to improve midwife productivity

▪ Ensure choice of location for birth, based on risk profile:– Provide high quality information e.g. risk profile of different units– Default option midwife led– Ensure clear transfer protocols for rapid transfer

▪ Ensure appropriate site staffing based on risk:– Low risk: Midwives– Medium/High risk: Midwifery, obstetric & medical consultants,

anaesthetics, ICU, neonatal ICU– Supra-specialist: Level 3 critical care, maternal and neonatal ICU

care, anaesthetics, surgery, ICU, neonatal ICU– 60-98 hrs per week of consultant presence on labour ward rising

to 168hrs in future▪ Interdependencies include:– Medium risk: anaesthesia (1 duty, 1 available on call); NICU level 1

(could be level 2 depending on the number of deliveries), blood transfusion on-site, HDU

– High risk: Complex ultrasound, endocrinology, surgery, interventional radiology, critical care, 24/7 anaesthesia, NICU level 2, blood transfusion services

– Supra-specialist: Complex surgery, medical specialists, interventional radiology, critical care, 24/7 anaesthesia, NICU level 3

▪ Ensure clear transfer protocols for rapid transfer▪ Continuity of carer throughout antenatal, birth and post natal but esp.

1:1 care during established labour through increased midwife productivity (Better Births – National Maternity Review)

▪ Provide high quality, safe maternity services– Increase percentage of normal births in low risk settings– Provide formal clinical networks– Handle complexity through specialisation


REVISED PATHWAY3

▪ Provide high-quality, routine post-natal care focused on people who need it based on social risk and clinical need– Contact with Health

Visitor within 10-14 days post-birth

– Health visitors targeted at most needy families; consider appointments in local community centres/GP practices instead of home

▪ Leverage IT-enabled solutions to increase sharing of records and improve productivity in community-based care – also using MSWs

▪ Midwife and Health visitor (post 10 days) proactively support breastfeeding to increase initiation/rates at 3/6 months

▪ Provide accessible, targeted specialist post-natal care if needed

▪ Dedicated neonatal care –separate rota from paeds

▪ Implement level 1/2/3 neonatal care

41

People with LTCs and frailty: best practice care

Prevention Early diagnosis Ongoing care & managementEnd of life care / Palliative care

Access to specialist care


REVISED PATHWAY4

▪ Focus on whole population

▪ Attention to health behaviours across all groups

▪ Involvement of wider range of healthcare professionals e.g. pharmacists to provide health messages

▪ Early identification of people at risk of LTCs and preventative advice given/planned

▪ Early identification of frailty (use of frailty index included)

▪ Diagnosis and screening available locally (not required to be hospital) with diagnostic tools available for all healthcare professionals

▪ Same day access to urgent tests as required (e.g., X Ray, MRI, blood)

▪ Plans in place for all patients with a diagnosed LTC - are clear and access to services is easy

▪ Directory of services available in local systems accessible by patients for reference

▪ Mental health considered from early stage

▪ Secondary prevention in place e.g. falls service

▪ Conditions managed proactively, with mental wellbeing considered at all levels of care

▪ Clear plans in place for all patients with a diagnosed LTC and/or frailty - are clear and access to services is straightforward

▪ Care provided/managed by multidisciplinary support team (e.g., trained teams of specialists from acute, primary care, and community) –regular meetings in person and via video/virtual MDT meetings

▪ Individual/team responsible for each patient and ongoing review of care/adherence to plan

▪ Continuity of care maintained as much as possible

▪ Records are shared between all organisations -including ambulance, social care - and shared with patient and carers

▪ Emphasis on long-term self-care owned by patients; technology, public campaigns, social support, and community sessions used to educate patients

▪ Practitioners have easy access to experts to inform support without having patient escalated

▪ Remote access to information for patient and carer available

▪ Patients given advice on self management to prevent escalation of condition

▪ Extensive use of social prescribing

▪ Patients able to quickly obtain specialist opinion in most appropriate way possible - as close to home with minimum skill level required (from non-consultant to specialist)

▪ System linked throughout (GP and Community and Ambulance)

▪ Alternatives to hospital access available (e.g., intensive care teams, hospitals at home, day hospital, local acute care units, access to specialist primary care nurses)

▪ Patients clear on treatment escalation plans and have quick access to treatment if required

▪ Easy access to care plans and care records for family and carers

▪ Care provided in the most appropriate setting with emphasis on allowing patient to remain at home or as local as possible (e.g., community beds)

▪ Advanced care planning done in timely manner

42

People with LTCs and frailty: clinical standards and best practice evidence

▪ All people over the age of 65 or with long term conditions will be risk stratified with appropriate pro-active care plans but in place for moderate and high risk individuals (GMS Contract, 2014)

▪ All people over the age of 75 and people with multiple long term conditions will have a named GP

▪ All moderate and high risk people will have a named care coordinator who will support them in self-care and ensure continuity of care through health services (GMS Contract, 2014

▪ All people with long term conditions will be offered information and support in self care (Integrated care and support: our shared commitment, Dept of Health 2013)

▪ In the event of a crisis, people will be appropriately triaged, and where suitable, be assisted by a multi-disciplinary rapid response team which will provide them with care in their home, and where appropriate, put in place short term home support to aid recovery at home as an alternative to hospital admission (Birmingham Community Healthcare NHS Trust, 7 Day Rapid Response Service Case Study, NHS Improvement 2011)

▪ People approaching the end of life receive consistent care that is coordinated effectively across all relevant settings and services at any time of day or night, and delivered by practitioners who are aware of the person's current medical condition, care plan and preferences (NICE guidance: End of life care for adults, 2017)

Early diagnosis Ongoing care & management Access to specialist care End of life care / Palliative care


REVISED PATHWAY4

44






– Shortlisting and initial combinations

– Detailed descriptions of clinical models

– Activity shift assumptions


Contents

45

Conceptual approach: the filtering process has narrowed down the longlist of potential models to a shortlist plus the status quo

Conceptual approach to clinical model development

Consider interdependencies to develop specialty combinations

Narrow clinical models based on high level criteria and keeping meaningfully different models only

Describe final models shortlist for full quality of care assessment

Long list of all combinations of clinical models for key service areas

Models viable from a clinical interdependency perspective, excluding current state

Models to be modelled

Identify possible range of service line models for key service areas:

▪ A&E

▪ Acute medicine

▪ Emergency surgery

▪ Critical care

▪ Elective surgery

▪ Maternity

▪ Paediatrics

1 2 3 4

Description

1 A representative sample of potential models for each clinical service lines were described, taking into account population needs

2 Combined into whole hospital clinical models taking into account interdependencies

3 Shortlist narrowed by keeping only meaningfully distinct models.▪ 6 distinct models for urgent

and emergency care are described

▪ The model for elective surgery was informed by the model of urgent and emergency care

▪ Models for paeds/maternity were informed by interdependencies with the model of urgent and emergency care

4 Eight models described following refinement with CRG

CLINICAL MODELS

46

Practical approach: shortlist of whole-hospital models was built by considering interdependencies, viability1 and distinctness in four stages

Practical approach to clinical model development

Stage one:

Narrow down UEC2

models

Stage two:

Combine UEC models with elective care model options

Stage three:

Combine UEC & elective care models with paediatric & maternity models

Stage four:

Combine with frailty / elderly care models to get whole-hospital clinical models

1 Based on reference to the evaluation criteria2 UEC is urgent and emergency care and comprises A&E, acute medicine, emergency surgery,

and critical care

CLINICAL MODELS

47

Standardised care pathways

Common approaches (integration) across whole system

Easy access to senior decision makers – on site or remotely

Remote access to specialist opinion

Mental health crisis teams available, ideally in ED/UTC

Stabilisation and rapid transfer for patients needing escalation

Transfer back from specialist centres to local units

Greater use of hot clinics

Incentivisation of recruitment & retention by developing a USP

Enhanced use of IT/technology (e.g. telemedicine, virtual clinics)

Easy step-down or transfer to community / social settings

The importance of key enablers for all modelsCLINICAL MODELS

48

A range of clinical models exist for each serviceService offering Range of models explored

Frailty Frailty unit/hub included in all configurations

Emergency surgery

OOH gen. surgery registrar (with cons support from York)

Surgery hot clinics (SAU + recovery beds)

24 x 7 emergency general surgery

Ambulatory emergency surgery only

Critical care L2 critical care+/- eICU No enhanced careL3 critical care +/- eICUL1 care plus critical care service

Elective careModerate perioperative risk elective surgery

Day cases only High perioperative risk elective surgery

Low perioperative risk elective surgery

PaediatricsPaediatric assessment unit (all walk-ins & referrals) UTC onlyInpatient

MDT led care at Front door (no paediatrician)

MaternityLower risk obstetric service with limited neonates (L1)

On-call midwife-led unit

High risk obstetric service24/7 on-site midwife-led unit

Acute medicineSelective acute take with AAU

Step up/Step down beds24 x7acute medical take with AAU

Ambulatory Assessment unit (AAU) only – no beds

A&EFront door assessment A&E model UTC only24x 7 A&E

“Medical only” A&E + UTC

Service line models can be combined to form thousands of combinations of whole-hospital clinical models

CLINICAL MODELS

49

Combining all potential UEC models alone leads to 256 potential combinations

1 Critical care support could be provided for unstable patient by anaesthetics/critical care physicians with Critical Care Outreach Team

Does not account for service lines such as maternity and paediatrics which would result in thousands of combinations

Assuming no interdependencies

Acute medicine

Critical care

Emergen-cy surgery

Rationale

No. of models

256

64 64 64

2

3

2

3

1

4

2

3

1

4

4

1

Level 2 + HDU

Level 1 plus critical care service1

Selective take

AAU only

Level 3 +/- eICU

No enhanced care

OOH reg on site (cons support at York)


24/7 emergency gen. surgery

Hot clinics only

Step up/down beds

Full medical take

Medical only A&E

2

3

2

3

1

4

2

3

1

4

4

1

Level 2 + HDU


Selective take

AAU only

Level 3 +/- eICU

No enhanced care




Hot clinics only

Step up/down beds

Full medical take

Front door assessment A&E model

64

2

3

2

3

1

4

2

3

1

4

4

1

Level 2 + HDU


Selective take

AAU only

Level 3 +/- eICU

No enhanced care




Hot clinics only

Step up/down beds

Full medical take

UTC only24/7 A&E

2

3

2

3

1

4

2

3

1

4

4

1

Level 2 + HDU


Selective take

AAU only

Level 3 +/- eICU

No enhanced care




Hot clinics only

Step up/down beds

Full medical take

CLINICAL MODELS

50

Stage one: clinical interdependencies within urgent and emergency care exclude some clinical models

Key interdependenciesServices

Assumes diagnostic imaging and pathology services exist in all models

▪ 24/7 A&E requires a core level of anaesthetics / critical care and medical support

▪ Front door assessment A&E model requires at least on call gen surgery

▪ UTC only does not require emergency surgery or critical care

A&E

▪ Full (unselected) acute medicine take requires access to critical care and access to emergency surgery

Acute medicine

▪ Providing inpatient emergency surgery requires L3 critical care▪ Providing inpatient emergency surgery requires acute medicine

Emergencysurgery

Critical care▪ Would not provide critical care without acute medicine take

Major trauma▪ Scarborough may need to retain trauma unit status to satisfy trauma

network requirements, which may require 24/7 emergency surgery and a consultant surgeon within 30 mins1

1 Trauma unit status would not require inpatient paediatrics, but may require 24/7 emergency surgery. This is based on initial discussions and guidance from the National Clinical Director for Trauma. Formal, written guidance has been requested by the steering group regarding this point. In the meantime it is important from a process point of view that we continue to consider and lay out the trade-offs across a broad range of clinical model options

CLINICAL MODELS

51

Stage one: filtering for first round of UEC interdependencies leads to 28 models

1 Refers to configuration of Emergency general surgery - in all models with trauma and orthopaedic in-patient services, non-resident registrar and consultant cover is considered

2 Critical care support could be provided for unstable patient by anaesthetics/critical care physicians with Critical Care Outreach Team

3 Includes imaging modalities which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures

Assumes diagnostic imaging3 and pathology services exist in all models

Acute medicine

Critical care

Emergen-cy surgery1

No. of models

28

2 12 12

2

3

2

3

1

4

2

3

1

4

4

1

Level 2 + HDU


Selective take

AAU only

Level 3 +/- eICU

No enhanced care




Hot clinics only

Step up/down beds

Full medical take

Medical only A&E

2

3

2

3

1

4

2

3

1

4

4

1

Level 2 + HDU


Selective take

AAU only

Level 3 +/- eICU

No enhanced care




Hot clinics only

Step up/down beds

Full medical take


2

2

3

2

3

1

4

2

3

1

4

4

1

Level 2 + HDU


Selective take

AAU only

Level 3 +/- eICU

No enhanced care




Hot clinics only

Step up/down beds

Full medical take

UTC only24/7 A&E

2

3

2

3

1

4

2

3

1

4

4

1

Level 2 + HDU


Selective take

AAU only

Level 3 +/- eICU

No enhanced care




Hot clinics only

Step up/down beds

Full medical take

CLINICAL MODELS

52

Stage one: more detail on the 28 potential clinical models for urgent and emergency care


Model 5 Model 6 Model 11 Model 12 Model 13Model 7 Model 8 Model 9 Model 10Model 1 Model 2 Model 3 Model 4

Level 2 Level 2 Level 2 Level 2 Level 2 Level 1 plus critical care service

Level 2 Level 1 plus critical care service

Level 1 plus critical care service


Level 3 Level 3 Level 3 Level 3

Model 14

A&EMedical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

24/7 A&E 24/7 A&E Front door ass’mentA&E model

Front door ass’mentA&E model

Emergency surgery1





Surgical hot clinics






24x7 emergency gen. surgery




Acute medicine

Full medical take + AAU


Selective medical take + AAU












Model 19 Model 20 Model 25 Model 26 Model 27 Model 28Model 21 Model 22 Model 23 Model 24Model 15 Model 16 Model 17 Model 18

Emergencysurgery1



Ambula-tory emer-gencysurgery only












Acute medicine



Step up/down beds

Step up/down beds

Step up/down beds

Step up/down beds

AAU only AAU only AAU only AAU onlySelective medical take + AAU




Critical care


No enhanced care


No enhanced care


No enhanced care


No enhanced care


No enhanced care




No enhanced care

A&EUTC only UTC only UTC only UTC only UTC only UTC onlyUTC only UTC only UTC only UTC onlyMedical

only A&EMedical only A&E

UTC only UTC only

Critical care

1 Refers to configuration of Emergency general surgery. In all models with trauma and orthopaedic in-patient services, non-resident registrar and consultant cover is considered


CLINICAL MODELS

53

Stage one: there are six meaningfully distinct UEC models were identified

1 1 Refers to configuration of Emergency general surgery. In all models with trauma and orthopaedic in-patient services, non-resident registrar and consultant cover is considered


CLINICAL MODELS


Model 5 Model 6 Model 11 Model 12 Model 13Model 7 Model 8 Model 9 Model 10Model 1 Model 2 Model 3 Model 4

Level 2 Level 2 Level 2 Level 2 Level 2 Level 1 plus critical care service




Level 3 Level 3 Level 3 Level 3

Model 14

A&EMedical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

Medical only A&E

24/7 A&E 24/7 A&E Front door ass’mentA&E model

Front door ass’mentA&E model

Emergency surgery1















Acute medicine















Model 19 Model 20 Model 25 Model 26 Model 27 Model 28Model 21 Model 22 Model 23 Model 24Model 15 Model 16 Model 17 Model 18

Emergencysurgery1



Ambula-tory emer-gencysurgery only












Acute medicine



Step up/down beds

Step up/down beds

Step up/down beds

Step up/down beds

AAU only AAU only AAU only AAU onlySelective medical take + AAU




Critical care


No enhanced care


No enhanced care


No enhanced care


No enhanced care


No enhanced care




No enhanced care

A&EUTC only UTC only UTC only UTC only UTC only UTC onlyUTC only UTC only UTC only UTC onlyMedical

only A&EMedical only A&E

UTC only UTC only

Critical care

54

Stage two: interdependencies determine what type of elective care the UEC models can provide

Key interdependenciesMajor services

▪ Would not provide high perioperative risk1 elective surgery without at least L2 critical care

Elective surgery


1 Perioperative risk takes into account the extent and complexity of the surgery as well as the pre-morbid state of the patient. The provision of critical care (to provide increased monitoring and therapies) and the availability of emergency surgery (to manage complications of elective surgery) will impact the elective procedures that can be performed


CLINICAL MODELS

55

Stage two: the UEC model determines the complexity of the elective care provided Highest level of elective surgery that can be provided



Model 28Model 1 Model 11 Model 17Model 4

Combined with one of elective care options available:

Model 15

Critical careNo enhanced careLevel 3 Level 2 Level 1 plus critical

care serviceLevel 3 Level 1 plus critical

care service

A&EUTC only24/7 A&E Medical only

A&EUTC onlyFront door

assessment A&E model

Medical only A&E

Emergency surgerySurgical hot clinics

24x7 emergency general surgery





Acute medicineStep up/down beds







Cases with low peri-operative risk2

c

Cases with moderate peri-operative risk2

b

Cases with high peri-operative risk2

a

CLINICAL MODELS

56

Stage two: There are six UEC + elective care models

Model 28Model 1 Model 11 Model 17Model 4 Model 15

Critical care

No enhanced care

Level 3 Level 2 Level 1 plus critical care service


A&E

UTC only24/7 A&E Medical only A&E

UTC onlyFront door assessment model

Medical only A&E

Emergency surgery







Acute medicine

Step up/down beds






Elective surgery1

Cases with low peri-operative risk

Cases with high peri-operative risk


Cases with moderate peri-operative risk


Cases with moderate peri-operative risk


CLINICAL MODELS

57

Stage three: interdependencies between paediatrics and maternity exclude some clinical models

Key interdependenciesMajor services

▪ Would not provide service for patients with high risk of neonatal critical care without inpatient paediatrics

Neonates

▪ Would not provide higher risk obstetrics without level 3 adult critical care and inpatient paediatrics

Maternity



CLINICAL MODELS

58

Stage three: There are seven distinct models for paediatrics & maternity

Paediatrics

Maternity

Model B

Inpatient

Lower risk obstetric service with limited neonates

Model D

Paediatricassess-mentunit

24/7 midwife led unit

Model E

MDT led care (no paedsconsultant)


Model F

UTC with no facility for children


Model A

Inpatient

High risk obstetric service

Model G

UTC with no facility for children

Pop-up midwife led unit

Model C

Paediatricassess-mentunit

Lower risk obstetric service with limited neonates


▪ These seven paediatric + maternity models are combined with the six UEC & elective care models (from first and second round) to form distinct and viable combinations

▪ Assumes diagnostic imaging1 and pathology services exist in all models

CLINICAL MODELS

59

Stage three: There are eight distinct models which combine UEC + elective with paediatrics + maternity

Model 28FModel 1C Model 11C Model 17DModel 4B Model 4C Model 15C


Model 1A

PaediatricsMDT led carePaeds

assessment unit

Paeds assessment unit


Inpatient paediatrics




MaternityMidwife led unit

Lower risk consultant led obstetrics

Midwife led unit

Midwife led unit



Midwife led unit

High risk obstetrics

Critical careNo enhanced care



Level 3



assessment model

Front door assessment model

Medical only A&E

24/7 A&E

Emergency surgery









Acute medicine

Step up/down beds








Elective surgery







Cases with moderate perioperative risk

Cases with high peri-operative risk1

1 Perioperative risk takes into account the extent and complexity of the surgery as well as the pre-morbid state of the patient


CLINICAL MODELS

60

Stage four: Combining clinical models with frailty / elderly care options

Key interdependencies and logic criteriaMajor services

▪ Frailty unit / service to be included in all configurationsFrailty / elderly care



CLINICAL MODELS

61

Stage four: initial shortlist of models circulated to CRG

Model 28FModel 1C Model 11C Model 17DModel 4B Model 4C Model 15CModel 1A

Paediatrics

MDT led carePaeds assessment unit







Maternity

Midwife led unit


Midwife led unit

Midwife led unit



Midwife led unit

High risk obstetrics

Critical care

No enhanced care



Level 3



assessment A&E model


Medical only A&E

24/7 A&E

Emergency surgery









Acute medicine

Step up/down beds








Elective surgery









▪ Frailty unit / service included in all configurations▪ Assumes diagnostic imaging1 and pathology services exist in all models


CLINICAL MODELS

62

The shortlisted models were revised based on feedback from the CRG, including removing the description of a low risk obstetrics unit


2 Model could also be delivered with lower risk consultant led obstetrics in place of Midwife led unit

CLINICAL MODELS

Model 17DModel 1C Model 4C Model 15DModel 3C Model 4A Model 11DModel 1A

Paediatrics







Paeds assessment uni2


Maternity

Midwife led unit2

Consultant led obstetrics


Midwife led unit2



Midwife led unit2


Critical care



Level 3 Level 3 Level 2Level 3

A&EMedical only A&E

24x7 A&E Front door assessment A&E model

UTC onlyFront door assessment A&E model


Medical only A&E

24x7 A&E

Emergency surgery









Acute medicine









Elective surgery









▪ Frailty unit / service included in all configurations▪ Assumes diagnostic imaging1 and pathology services exist in all models

63










Contents

64

Potential acute service models for Scarborough Hospital

Enablers common to all models

Developing a USP to support recruitment

Enhanced use of IT and technology

Easy (stabilise) & transfer of pts as req.

Clinical pathways featuring in all models

Diagnostic imaging & pathology services

1A

24 x 7 medical take + AAU


24 x 7 A&E + UTC

Level 3 critical care

High peri-operative risk elective surgery



1C



24 x 7 A&E + UTC



Paediatric assessment unit


3C



Front door assessment A&E + UTC





4A


OOH gen. surg. reg on site






4C








11D

Selective medical take +AAU


Medical only A&E + UTC




Midwife led unit1

15D


Ambulatory emergency surgery


Level 1 plus critical care

Moderate peri-op risk elective surgery


Midwife led unit1

17D


Ambulatory emergency surgery

UTC only

Level 1 plus critical care

Moderate peri-op risk elective surgery


Midwife led unit

Standardised care pathways

Common approaches across system

Frailty unit & hub

Easy access to senior decision maker

Remote access to specialist opinion

Mental health crisis teams

Greater use of hot clinics


DETAILED MODEL DESCRIPTIONS

65

Model 1A – 24 x 7 A&E + UTC, full medical take, 24 x 7 emergency surgery, L3 critical care, high peri-op risk electives, inpatient paeds, cons. led obs

1 NB – direct referrals from community GPs to AAU and Surgical assessment not included2 Frailty unit/service may be housed as part of assessment unit. It reflect specific pathways

and services to support older, frail patients and does not necessarily require a specific ward or area to deliver this service

Discharge

Admit

Discharge

Stabilise & transfer totertiary centres

Level 3Critical care

AMB

Ward

Discharge

Assessment


High perioperative risk elective surgery

TRIAGE

Admit

Diagn-ostics

Admit to SAU

Accident & Emergency24x7

Full medical take & Medical Assessment Unit (MAU)

Surgical Assessment Unit (SAU)


Non-urgent care

Stabilise & transfer

DischargeFrailty Assessment

Non-major cases

Frailty Unit/Service2

Acutelyunwell

Under 16

Frail over 75s

Urgent Treatment Centre (UTC)

Treatminorinjury

Direct admit MAU/SAU

ENP or GP

ANP GP

Initial care

Discharge


Discharge

66

Model 1A – 24 x 7 A&E + UTC, full medical take, 24 x 7 emergency surgery, L3 critical care, high peri-op risk electives, inpatient paeds, cons. led obs

1 For small DGH the assumption is that this would require 8- 10 WTE consultants 2 May require transfer and stabilisation of the patient to provide treatment in emergency situations 3 Includes imaging modalities which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures 3 Reports aspirational situation - at present 24 x 7 NCEPOD theatre not provided

Conditions Covered Conditions not coveredOther services requiredStaffing

24 x 7 medical take & AAU

▪ All acute medical admissions except for hyper-acute stroke and PPCI

▪ Hyper acute stroke patients▪ PPCI▪ Acute haematology/oncology2

▪ Level 3 critical care▪ IR and acute bleed service accessible through

standardised pathways2

▪ Frailty service▪ Diagnostics ▪ Standardised care pathways with GP admits

direct to AAU/frailty unit

▪ Acute or General medicine consultant on site 15 x 7; on-call and within 30 minutes OOH

▪ 24 x 7 medical registrar on site


▪ All emergency general surgery procedures and trauma & orthopaedic proceeds not requiring specialist tertiary care

▪ Specialist surgical procedures that require transfer to a specialist centre (e.g., vascular, neurosurgery)



▪ NCEPOD staffed theatre 24 x 73

▪ 24 x 7 general surgery consultant for emergency surgery on site in-hours. Consultant available within 30 mins OOH

▪ Surgical registrar OOH and consultant on-call▪ 24 x 7 Access to trauma and orthopaedic surgery▪ Anaesthetist available


▪ Full range of elective surgical procedures that do not require super-specialist or tertiary centre input

▪ Supra-specialist surgical procedures performed in national centres (e.g., vascular, neurosurgery)

▪ At least Level 2 critical care▪ Access to endoscopy2

▪ Access to interventional radiology2

▪ Full surgical team & OOH cover provided by surgical specialities; on-call anaesthetic consultant

▪ Consultant level in-hours (available within 30 mins OOH) + Resident junior OOH cover

Obstetric unit

▪ Low and high risk births >32 weeks of gestation▪ Acute/emergency gynaecology▪ Antenatal care in day assessment unit or in

community▪ Postnatal care in hospital if complex or community

(short stay in unit after birth)▪ Elective gynae

▪ Women with complex conditions requiring treatment at specialist centres (e.g. congenital heart disease)

▪ Women with pregnancies requiring specialist foetal medicine

▪ Women at risk of delivery below 32 weeks gestation2

▪ Level 3 critical care▪ Acute/emergency gynae▪ Dedicated obstetric operating theatre

▪ 12 x 7 consultant obstetrician on labour unit (OOH on-call consultant available on-site)

▪ 24 x 7 immediate paediatric cover and neonatal care▪ 24 x 7 midwifery on site▪ 24 x 7 immediate access to anaesthetist▪ Theatre team on-site


▪ Level 3 patients - requiring two or more organ support (or requiring invasive ventilation or CVVH)

▪ Cases requiring specialist tertiary centre ITU (e.g. neuro, cardiac, liver)

▪ 24 x 7 Anesthetic consultant cover▪ 12 x 7 Critical care consultant cover with remote support from

York OOH▪ Non-consultant grade Anaesthetist resident on-call

Inpatient paeds

▪ All acute general paediatric illnesses requiring admission

▪ Common care pathways across patch

▪ Acutely unwell children requiring paedscritical care support

▪ Children requiring admissions▪ Neonates requiring level 2 or 3 neonatal

care

▪ Stabilise and transfer capability for critically ill children

▪ Regional neonatal transport service for L2/3 care2

▪ 10 WTE consultant paediatricians to cover 24 x 7 rota (on-site and immediate available in hours; on site within 30 mins OOH)

▪ 24 x 7 resident non-consultant grade doctor

24 x 7 A&E

▪ All A&E attendances and GP referrals▪ GP out-of-hours services at UTC▪ Trauma patients (including those suitable for a

trauma unit)

▪ Major complex conditions needing treatment at specialist centres (e.g. polytrauma, hyper acute stroke, PPCI)

▪ Level 3 critical care▪ NCEPOD staffed theatre 24x7▪ IR and acute bleed service accessible through


▪ Frailty service▪ Primary care front door ▪ Stabilise and transfer patients requiring care at

another site

▪ ED consultant in person 16 x 7; available within 20 mins OOH1

▪ Additional complement of Tier 1 and 2 practitioners (incl. Mental Health)

▪ Diagnosticians▪ Multidisciplinary team to support frailty service



67

Model 1C – 24 x 7 A&E + UTC, full medical take, 24 x 7 emergency surgery, L3 critical care, high peri-op risk electives, SSPAU, lower risk obs



Discharge

Admit

Discharge

Stabilise & transfer toother centres


AMB

Ward

Discharge

Assessment

Lower risk obstetrics


TRIAGE

Admit

Diagn-ostics

Admit to SAU

Accident & Emergency24x7

Full medical take & Medical Assessment Unit (MAU)


Short Stay PaediatricUnit (SSPAU)

Non-urgent care

Discharge



Non-major cases

Frailty Unit &Hub2

Acutelyunwell

Under 16

Frail over 75s


Treatminorinjury


ENP or GP

ANP GP

Initial care

Discharge


68

Model 1C – 24 x 7 A&E + UTC, full medical take, 24 x 7 emergency surgery, L3 critical care, high peri-op risk electives, SSPAU, lower risk obs

1 Modelled as 15 hours per day but configurations open up to 24 hours per day could be considered (where consultant could be on site 12 x 7 and available within 30 mins OOH)

2 For small DGH the assumption is that this would require 8- 10 WTE consultants 3 May require transfer of the patient to provide treatment 4 Includes imaging modalities

which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures 5 Reports aspirational situation - at present 24 x 7 NCEPOD theatre not provided




▪ All A&E attendances and GP referrals▪ GP out-of-hours services at UTC▪ Trauma patients (including those suitable for a trauma

unit)


▪ Level 3 critical care▪ NCEPOD staffed theatre 24x7▪ IR and acute bleed service accessible through


▪ Frailty service▪ Primary care front door ▪ Stabilise and transfer patients requiring care at

another site

▪ ED consultant in person 16 x 7; available within 20 mins OOH1

▪ Additional complement of Tier 1 and 2 practitioners (incl. Mental Health)

▪ Diagnosticians▪ Multidisciplinary team to support frailty service

24 x 7 A&E

▪ Lower risk births >36 weeks of gestation▪ Acute/ Emergency gynaecology▪ Antenatal care in day assessment unit or in community▪ Postnatal care in hospital if complex or community

(short stay in unit after birth)

▪ Women with complex conditions requiring treatment at specialist centres (e.g. Congenital heart disease)


▪ Women at risk of delivery below 36 weeks gestation


▪ 12 x 7 consultant obstetrician on labour unit (OOH on-call obstetrician available within 30 minutes)

▪ 24 x 7 on-site non-consultant grade obstetrician▪ 24 x 7 immediate access to advanced neonatal resuscitation (e.g.

ANNP, Middle-grade or Reg Neonates)▪ 24 x 7 midwifery on site▪ 24 x 7 immediate access to anaesthetist

Obstetric unit

▪ Minor acute illnesses, minor trauma, burns and infections, IV antibiotics

▪ Acutely unwell children transferred to hospital with inpatient paediatrics

▪ Repatriate cases from York ED if appropriate

▪ Illness requiring >8 hours observation▪ Children likely to require inpatient surgery▪ Children likely require inpatient admissions▪ Neonates requiring level 2/3 NICU


▪ Regional neonatal transport service▪ Standardised protocols for transfer of patients

requiring inpatient care

▪ Consultant paediatrician on site 15 x 7▪ Shared staff with A&E with paediatric expert / ANP / SpR covering

OOH▪ Facilities for children available 7 days through SSPAU and ED/UTC

SSPAU1 + ambulatory care


▪ Hyper-acute stroke patients▪ PPCI▪ Acute haematology/oncology2



▪ Frailty service▪ Diagnostics ▪ Standardised care pathways with GP admits direct

to AAU/frailty unit


▪ 24 x 7 medical registrar on site24 x 7 medical take & AAU



▪ Children likely to require surgery









▪ 24 x 7 Anesthetic consultant cover▪ 12 x 7 Critical care cover with remote support from York OOH▪ Non-consultant grade anaesthetist resident on-call



▪ Supra-specialist surgical procedures performed in national centres (e.g., vascular, neurosurgery)

▪ Level 2 critical care▪ Access to endoscopy3





69

Model 3C – Front door assessment A&E model, full medical take, 24 x 7 emergency surgery, L3 critical care, high peri-op risk electives, SSPAU, lower risk obs



Discharge

Admit

Discharge



AMB

Ward

Discharge

Assessment



TRIAGE

Admit

Diagn-ostics

Admit to SAU

Accident & Emergency24x7 with seniordecision maker

Full surgical and medical take with combined emergency assessment unit (CEAU)

Short Stay PaediatricUnit (SSPAU)

Non-urgent care



Non-major cases

Frailty Unit &Hub2

Acutelyunwell

Under 16

Frail over 75s


Treatminorinjury

Direct admit CEAU

ENP or GP

ANP GP

Initial care

Discharge


Discharge

70

Model 3C – Front door assessment A&E model, full medical take, 24 x 7 emergency surgery, L3 critical care, high peri-op risk electives, SSPAU, lower risk obs


2 May require transfer of the patient to provide treatment 3 Includes imaging modalities which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures 4 Reports aspirational situation - at present 24 x 7 NCEPOD theatre not provided



Obstetric unit










24 x 7 medical take & AAU


▪ Hyper-acute stroke patients▪ PPCI▪ Acute haematology/oncology2




to CEAU















▪ 24 x 7 Anesthetic consultant cover▪ 12 x 7 Critical care consultant cover with remote support from York

OOH▪ Non-consultant grade anaesthetist resident on-call



▪ Super-specialist surgical procedures performed in national centres (e.g., vascular, neurosurgery)

▪ At least level 2 critical care▪ Access to endoscopy2












▪ Cons. paediatrician on site 15 x 7▪ Shared staff with A&E with paediatric expert / ANP / SpR covering

OOH▪ Facilities for children available 7 days through SSPAU and ED/UTC

▪ All A&E attendances and GP referrals▪ GP out of hours services at UTC▪ Trauma patients (including those suitable for a trauma

unit)


▪ Level 3 critical care▪ Combined Emergency assessment unit▪ NCEPOD staffed theatre 24x7▪ IR and acute bleed service accessible through


▪ Primary care front door ▪ Stabilise and transfer patients requiring care at

another site

▪ Senior decision maker with appropriate skill set (e.g. Gen surgery or ED to see abdominal pain)

▪ Multidisciplinary ‘total medical workforce” to see patients at front door

▪ Advanced Nurse Practitioner (ANP) support▪ HCAs



71

Model 4A – Front door assessment A&E model, full medical take, OOH gen. surg. regon-call, high peri-op risk electives, L3 critical care, inpatient paeds, cons. led obs



Discharge

Admit

Discharge



AMB

Ward

Discharge

Assessment



TRIAGE

Admit

Diagn-ostics

Admit to SAU


Full medical take, OOH gen/ surg. reg on call & Combined emergency assessment unit (CEAU)


Non-urgent care



Non-major cases

Frailty Unit &Hub2

Acutelyunwell

Under 16

Frail over 75s


Treatminorinjury

Direct admit CEAU

ENP or GP

ANP GP

Initial care

Discharge


Discharge

72

Model 4A – Front door assessment A&E model, full medical take, OOH gen. surg. regon-call, high peri-op risk electives, L3 critical care, inpatient paeds, cons. led obs

1 May necessitate transfer of the patient to provide treatment 2 Includes imaging modalities which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures 3 Would be available for advice with capability to attend Scarborough if patient requiring surgery is too unstable to be transferred. Would require expansion of current general surgical consultant rota





▪ Hyper acute stroke patients▪ PPCI▪ Acute haematology/oncology2




to CEAU



OOH general surgery on-call reg.

▪ All trauma and orthopaedic procedures not requiring specialist tertiary care

▪ All general surgical admissions not requiring surgery overnight or tertiary centre input


▪ At least level 2 critical care with capacity and capability to ventilate and resuscitate

▪ NCEPOD staffed theatre 12 x 7; on-call team overnight

▪ Transfer of patients requiring urgent overnight surgical intervention

▪ 12 x 7 general surgery consultant on site▪ Surgical registrar or middle grade OOH with remote cons. support at

York▪ 24 x 7 Access to trauma and orthopaedic surgery▪ 24 x 7 Access to anaesthetics/critical care▪ 2nd on call consultant availability at York3



unit)


▪ Level 3 critical care▪ Combined Emergency assessment unit▪ NCEPOD staffed theatre 24 x 7▪ IR and acute bleed service accessible through



another site

▪ Senior decision maker with appropriate skill set (e.g. General surgery or ED to see abdominal pain)





▪ Cases requiring specialist tertiary centre ITU (e.g. Neuro, Cardiac, Liver)


OOH▪ Non-consultant grade anaesthetist resident on-call




▪ At least Level 2 critical care▪ Access to endoscopy1



▪ Consultant level in-hours + OOH resident junior (OOH hours consultant support from York)

Obstetric unit

▪ Low and high risk births >32 weeks of gestation▪ Acute/emergency gynaecology▪ Antenatal care in day assessment unit or in community▪ Postnatal care in hospital if complex or community

(short stay in unit after birth)▪ Elective gynae



▪ Women at risk of delivery below 32 weeks gestation2


▪ 12 x 7 consultant obstetrician on labour unit (OOH on-call consultant available on-site)

▪ 24 x 7 immediate paediatric cover and neonatal care▪ 24 x 7 midwifery on site▪ 24 x 7 immediate access to anaesthetist▪ Theatre team on-site

Inpatient paeds

▪ All acute general paediatric illnesses requiring admission

▪ Common care pathways across patch

▪ Acutely unwell children requiring paedscritical care support

▪ Neonates requiring Level 2 or 3 neonatal care


▪ Regional neonatal transport service for L2/3 care

▪ 10 WTE consultant paediatricians to cover 24 x 7 rota (on-site and immediate available in hours; on site within 30 mins OOH)

▪ 24 x 7 resident non-consultant grade doctor


73

Model 4C – Front door assessment A&E model, full medical take, OOH gen. surg. regon-call, high peri-op risk electives, L3 critical care, SSPAU, lower risk obs



Discharge

Admit

Discharge



AMB

Ward

Discharge

Assessment



TRIAGE

Admit

Diagn-ostics

Admit to SAU


Full medical take, OOH gen/ surg. reg on call & Combined emergency assessment unit (CEAU)

Short stay PaediatricAssessment Unit (SSPAU)

Non-urgent care



Non-major cases

Frailty Unit &Hub2

Acutelyunwell

Under 16

Frail over 75s


Treatminorinjury

Direct admit CEAU

ENP or GP

ANP GP

Initial care

Discharge


Discharge

74

Model 4C – Front door assessment A&E model, full medical take, OOH gen. surg. regon-call, high peri-op risk electives, L3 critical care, SSPAU, lower risk obs


2 May require transfer of the patient to provide treatment 3 Includes imaging modalities which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures 4 Would be available for advice with capability to attend Scarborough if patient requiring surgery is too unstable to be transferred. Would require expansion of current general surgical consultant rota




Obstetric unit


















▪ Consultant paediatrician on site 15 x 71

▪ Shared staff with A&E with paediatric expert / ANP / SpR covering OOH

▪ Facilities for children available 7 days through SSPAU and ED/UTC

24 x 7 medical take + MAU


▪ Hyper-acute stroke patients ▪ PPCI▪ Acute haematology/oncology2




to CEAU






▪ Specialist surgical procedures that require transfer to a specialist centre e.g., vascular, neurosurgery)





▪ 12 x 7 general surgery consultant on site▪ Surgical registrar or middle grade OOH with remote cons. support at

York▪ 24 x 7 Access to trauma and orthopaedic surgery▪ 24 x 7 Access to anaesthetics/critical care▪ 2nd on call consultant availability at York4





OOH▪ Non-consultant grade Anaesthetist resident on-call









unit)


▪ Level 3 critical care▪ Combined Emergency assessment unit▪ NCEPOD staffed theatre 24x7▪ IR and acute bleed service accessible through



another site

▪ Senior decision maker with appropriate skill set (e.g. General surgery or ED to see abdominal pain)



Front door assessment model A&E

75

Model 11D – Medical A&E + UTC, selective take, OOH surgical reg. on-call, L2 critical care, high peri-op risk electives, SSPAU, MW-led unit

1 NB – direct referrals from community GPs to MAU & SAU not included in this 2 Frailty unit/service may be housed as part of assessment unit. It reflect specific pathways



Discharge

Admit

Discharge


AMB

Ward

Discharge

Assessment


TRIAGE

Admit

Diagn-ostics

Admit to SAU

Medical only A&E

Selective take & Medical assessment unit (MAU)



Frailty Assessment

Non-major cases

Frailty Unit &Hub2

Acutelyunwell

Under 16

Frail over 75s


Treatminorinjury


ENP or GP

ANP GP

Initial care

Discharge


Ambulatory CareUnit (ACU)

Non-urgent care

Discharge


Discharge


24 x 7 Midwife –led maternityUnit3

76

Model 11D – Medical A&E + UTC, selective take, OOH surgical reg on-call, L2 critical care, high peri-op risk elective surgery, SSPAU, MW-led unit

1 Modelled as 15 hours per day but configurations open up to 24 hours per day could be considered (where consultant could be on site 12 x 7 and available within 30 mins OOH) 2 May require transfer of the patient to provide treatment 3 Includes imaging modalities which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures 4 Would be available for advice with capability to attend Scarborough if patient requiring surgery is too unstable to be transferred. Would require expansion of current general surgical consultant rota 5 Model could also be delivered with lower risk consultant led obstetrics in place of Midwife led unit




Selective take + MAU

▪ All non- high acuity ▪ Stroke patients, hyper acute cardiac care, subset of patients requiring level 3 critical care

▪ Acute bleeds▪ Hepatology

▪ Acute assessment unit▪ Frailty service▪ Diagnostics▪ Standardised care pathways with GP admits direct

to AAU/frailty unit



24 x 7 Midwife led unit5

▪ Low risk births, 37 - 42 weeks of gestation▪ Antenatal care / in day assessment unit or in

community▪ Postnatal care in community (short stay in-unit after

birth)

▪ Women requiring obstetric care, high-risk pregnancies, maternal-foetal medicine, epidurals, C-sections

▪ Acute/emergency gynae

▪ Capacity to stabilise and transfer▪ Standardised protocols for in utero or neonatal

transfer within regional network▪ Gynae hot clinic

▪ 24 x 7 Midwife, support worker and HCA presence▪ Additional midwife support on call▪ Support staff▪ Primary care hubs for midwife clinics





▪ Illness requiring >8 hours observation▪ Children likely to require inpatient surgery▪ Children likely require inpatient admission▪ Neonates requiring level 2/3 NICU





▪ Shared staff with A&E with paediatric expert / ANP / SpR covering OOH









▪ 12 x 7 general surgery consultant on site▪ Surgical registrar OOH with remote cons. support at York▪ 24 x 7 Access to trauma and orthopaedic surgery▪ 24 x 7 Access to anaesthetics/critical care▪ 2nd on call consultant availability at York4


▪ Level 2 patients - single organ support (excluding mechanical ventilation) such as ionotropes and invasive BP monitoring

▪ Patients requiring multiple organ support▪ 24 x 7 anaesthetic consultant cover▪ 12 x 7 critical care consultant cover (remote support from York OOH)▪ Non-consultant grade anaesthetist resident OOH▪ Transfer team for step up and stabilise if required▪ 1:2 RN

▪ Capability to provide short term ventilation for patients awaiting transfer


▪ Super-specialist surgical procedures performed in national centres (e.g., neurosurgery, vascular surgery)






▪ Medical ED attendances, minor illnesses and injuries, GP referrals

▪ Stabilise and transfer others

▪ Surgical ED attendances e.g. patients requiring laparotomy

▪ Other complex needs (any life or limb threatening conditions); conditions requiring critical care

▪ Stabilise and transfer patients requiring care at another site

▪ MAU and frailty unit on site▪ Primary care front door

▪ ED/acute medicine consultant on site in hours; available within 30 mins OOH

▪ Stabilise & transfer team (anaesthetist + ODP/Crit care nurse) on site▪ Mental Health practitioner available ▪ Multidisciplinary team to support frailty unit


77

Model 15D – Medical A&E + UTC, selective take, ambulatory emergency surgery, L1 enhanced ward care, mod peri-op risk elective surgery, SSPAU, MW-led unit

1 NB – direct referrals from community GPs to MAU & SAU not included in this 2 Frailty unit/service may be housed as part of assessment unit. It reflect specific pathways



Discharge

Admit

Discharge

Ward

Discharge

Assessment

Admit

Diagn-ostics

Admit to SAU

Medical only A&E

Selective take & Medical assessment unit



Frailty Assessment

Non-major cases

Frailty Unit &Hub2

Acutelyunwell

Under 16

Frail over 75s


Treatminorinjury

Direct admit MAU/AES

ENP or GP

ANP GP

Initial care

Discharge

Ambulatory EmergencySurgery (AES)


Non-urgent care

Discharge

Frail over 75s

TRIAGE Stabilise & transfer to other centres

Major emergencies

Transfer to other centres

AMBTRIAGE


Discharge


Moderate peri-operative risk elective surgery


Step up to transfer to Level 2/3

78



Model 15D – Medical A&E + UTC, selective take, ambulatory emergency surgery, L1 enhanced ward care, mod peri-op risk elective surgery, SSPAU, MW-led unit


2 May require transfer of the patient to provide treatment 3 Includes imaging modalities which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures 4 Model could also be delivered with lower risk consultant led obstetrics in place of Midwife led unit



▪ All non- high acuity ▪ Patients already established on CPAP▪ Medical assessment unit▪ Frailty service▪ Diagnostics▪ Standardised care pathways with GP admits

direct to AAU/frailty unit

▪ 12 x 7 medicine consultant on site; on-call OOH and available on site within 30 mins


24 x 7 Midwife led unit4


community▪ Postnatal care in community (short stay in-unit

after birth)


▪ Acute/emergency gynae

▪ Capacity to stabilise and transfer▪ Standardised protocols for in utero or

neonatal transfer within regional network▪ Gynae hot clinic

▪ 24 x 7 Midwife, support worker and HCA presence▪ Additional midwife support on call▪ Support staff▪ Primary care hubs for midwife clinics





▪ Illness requiring >8 hours observation▪ Children likely to require inpatient surgery▪ Children likely require inpatient

admissions▪ Neonates requiring level 2/3 NICU





▪ Shared staff with A&E with paediatric expert / ANP / SpRcovering OOH


Amb emergsurgery only

▪ Ambulatory surgical activity e.g., abscess drainage, non-complex gall bladders, piles (add to DC lists)

▪ All emergency procedures not required within 12 hours

▪ All high risk patients and high complexity procedures

▪ Emergency laparotomy + all non-medical abdominal pain

▪ Capacity to stabilise and transfer▪ Dedicated surgical consultant on a limited rota (e.g. 10 x 7) and on standby to offer opinion

▪ NCEPOD theatre available for ~3 hours a day

▪ Capacity to stabilise and transfer ▪ Level 1 patients only – no organ support required▪ Patients already established on CPAP

▪ Patients requiring organ support (including vasopressor support)

▪ More intensive monitoring, (e.g. cardiac monitoring) supported by transfer team

▪ Access to anaesthetist 24 x 7▪ 1:4 RN



▪ All mid and low perioperative risk procedures▪ Endoscopy, IR + other procedures▪ On-call emergency surgery

▪ High complexity and / or high risk patients▪ Patients likely to require critical care

admissions perioperatively

▪ Level 1 enhanced ward▪ Capability to stabilise and transfer if urgent

intervention required OOH

▪ Full surgical team provided in hours; OOH support provided by junior with remote support from York

▪ 24 x 7 immediate access to anaesthetic support (on-call consultant available within 30 mins)

▪ Medical ED attendances, minor illnesses and injuries, GP referrals

▪ Stabilise and transfer others

▪ Surgical ED attendances e.g. patients requiring laparotomy

▪ Other complex needs (any life or limb threatening conditions); conditions requiring critical care


▪ Frailty service▪ Primary care front door

▪ ED/acute medicine consultant on site in hours; available within 30 mins OOH

▪ Stabilise & transfer team (anaesthetist + ODP) on site▪ Mental Health practitioner available ▪ Multidisciplinary team to support frailty service


79

Model 17D – UTC only, selective take, ambulatory emergency surgery, L1 enhanced ward care, moderate peri-op risk elective surgery, SSPAU, MW-led unit

1 NB – direct referrals from community GPs to MAU & SAU not included in this2 Frailty unit/service may be housed as part of assessment unit. It reflect specific pathways




Frailty Unit and Hub2

Non-urgent

care


Discharge

Selective take + Medical Assessment Unit (MAU)

Admit

Ward

Discharge

Frailty Assessment

Ambulatory EmergencySurgery (AES)

AMB

Frail over 75s

Non-major cases

TRIAGE

Discharge

Urgent Care Centre (UTC)

GP direct admits+ T&O pathways(e.g. #NOF)

Diagnostics

TRIAGE

Major emergencies

Transfer to other centres

Short Stay Paediatric Assessment Unit (SSPAU)

Under 16Treat

minorinjury

Direct admit MAU

ENP or GPANP GP

Initial care


Discharge



Level 1Care plus critical care services

Step up to transfer to Level 2/3

80



Model 17D – UTC only, selective take, ambulatory emergency surgery, L1 enhanced ward care, moderate peri-op risk elective surgery, SSPAU, MW-led unit

1 Modelled as 15 hours per day but configurations open up to 24 hours per day could be considered (where consultant could be on site 12 x 7 and available within 30 mins OOH) 2 Includes imaging modalities which do not require direct radiology supervision (e.g. can be interpreted by the referring clinician or reported remotely). Does not assume provision of interventional radiology procedures


Amb emergsurgery only

▪ Ambulatory surgical activity e.g., abscess drainage, non-complex gall bladders, piles (add to DC lists)

▪ All emergency procedures not required within 12 hours

▪ All high risk patients and high complexity procedures

▪ Emergency laparotomy + all non-medical abdominal pain

▪ Capacity to stabilise and transfer▪ Dedicated surgical consultant on a limited rota (e.g. 10 x 7) and on standby to offer opinion

▪ NCEPOD theatre available for ~3 hours a day

Moderate perioperative risk elective surgery

▪ All mid and low perioperative risk procedures▪ Endoscopy, IR + other procedures▪ On-call emergency surgery

▪ High complexity and / or high risk patients▪ Patients likely to require critical care

admissions perioperatively

▪ Level 1 enhanced ward▪ Capability to stabilise and transfer if urgent

intervention required OOH▪ Access to anaesthetic support 24 x 7

▪ Full surgical team provided in hours; OOH support provided by junior with remote support from York

▪ 24 x 7 immediate access to anaesthetic support (on-call consultant available within 30 mins)

24 x 7 Midwife led unit


community▪ Postnatal care in community (short stay in-unit

after birth)


▪ Capacity to stabilize and transfer▪ 24 x 7 Midwife, support worker and HCA presence▪ Additional midwife support on call▪ Support staff▪ Primary care hubs for midwife clinics


▪ All non- high acuity ▪ Stroke patients, hyper acute cardiac care, subset of patients requiring or at risk of requiring level 2/3 critical care

▪ Acute bleeds▪ Hepatology

▪ Frailty service▪ Diagnostics▪ Standardised care pathways with GP admits

direct to MAU

▪ 12 x 7 medicine consultant on site; on-call OOH and available on site within 30 mins






▪ Illness requiring >8 hours observation▪ Children likely to require inpatient surgery▪ Children likely require inpatient

admissions▪ Neonates requiring level 2/3 NICU





▪ Shared staff with A&E with paediatric expert / ANP / SpRcovering OOH



▪ Level 1 patients only – no organ support required▪ Patients already established on CPAP

▪ Patients requiring organ support (including vasopressor support)

▪ More intensive monitoring, e.g., cardiac monitoring supported by transfer team

▪ Access to anaesthetist 24 x 7▪ 1:4 RN

▪ Capacity to stabilise and transfer

▪ All minor illnesses and injury▪ Stabilise and transfer others

▪ Suspected complex fractures; other complex needs (any life or limb threatening conditions); conditions requiring critical care


▪ Possibly ambulatory care observation and assessment

▪ Frailty service

▪ GPs▪ Advanced Nurse Practitioner (ANP) support▪ HCAs▪ Multidisciplinary team of GPs, geriatricians, ANPs to support

frailty service▪ Mental Health practitioner available ▪ Remote access to A&E consultant

UTC only

81










Contents

82

Approach to preliminary activity shift assumptions

▪ Clinically-led judgement

▪ Based on interviews with Clinical Directors, Deputy Clinical Directors and other senior clinicians for key service lines

▪ Generally good alignment in perspectives between clinicians within service lines

▪ Assumptions selectively supported / informed by activity data e.g., proportion of “low risk” obstetrics patients

▪ Forms basis for more detailed bottom-up / prospective analysis of activity shifts in a later phase of work

ACTIVITY SHIFT ASSUMPTIONS

Application

Methodology

▪ Clinical activity requires bed capacity and brings income and expenditure with it

▪ Shifts in clinical activity are used to model shifts in bed capacity, income and expenditure between hospitals

These preliminary assumptions will need to be revisited as the clinical models are further developed ahead of any final evaluation

83

Clinical activity shift assumptions were developed for each model

Model 15DModel 3C Model 11D Model 17DModel 4A Model 4CModel 1A Model 1C

Paedia-trics

Obs and Gynae

A&E

Emerg-encygen. surgery

Acute medicine

Trauma & ortho-paedics

Majors 100 95 95 100 95 70 240

Minors 100 100 100 100 100 100 100100

Resus 100 97 97 100 95 65 140

Daycase 100 100 100 100 100 100 100100

Non-elective 100 100 100 95 95 90 4545

Elective 100 100 100 100 100 100 100100

Outpatient 100 100 100 100 100 100 100100

Daycase 100 100 100 100 100 100 100100

Non-elective 100 95 95 90 85 40 3030

Elective 100 100 100 100 100 100 6565

Outpatient 100 100 100 100 100 100 10095

Daycase 100 100 100 100 100 100 100100

Non-elective 100 95 95 100 100 40 3030

Elective 100 100 100 100 100 100 9595

Outpatient 100 100 100 100 100 100 13011301

Crit. care 100 100 100 90 90 70 1010

Outpatient 100 100 100 100 100 100 100100

Births 100 40 40 100 40 25 2525

Elective gynae 100 100 100 100 100 75 5050

Day case gynae 100 100 100 100 100 100 100100

Nonelective gynae 100 100 100 75 75 50 5050

Antenatal care 100 95 95 100 95 95 9595

Outpatient gynae 100 100 100 100 100 100 100100

Inpatient 100 60 60 95 60 60 6060

Neonates 100 25 25 100 25 0 00

SOURCE: Interviews with Clinical Directors and lead clinicians

1 OP likely to increase due to increased referrals to fracture clinic in UTC model

ACTIVITY SHIFT ASSUMPTIONS

X % of current Scarborough activity which would stay in Scarborough under each model

84







Contents

85

Taking into account clinical interdependencies, the CRG agreed to look at eight potential clinical models in more detail


▪ Frailty unit / hub included in all models▪ Assumes diagnostic imaging1 and pathology services exist in all models

Model 3C Model 11D Model 15DModel 4A Model 4CModel 1A Model 1C Model 17D

Paediatrics


Paeds assessment unit2







MaternityConsultant led obstetrics unit

Midwife led unit

Midwife led unit

Consultant led obstetrics unit




Midwife led unit

Critical care


Level 3 Level 3 Level 3 Level 3 Level 1 plus critical care service

A&E

24/7 A&E with front door assessment





24x7 A&E –consultant led


UTC only

Emergency surgery


OOH middle grade on site (cons support from York)







Acute medicine









Elective surgery









EVALUATION OF CLINICAL MODEL

86

These were subsequently reduced to five clinical models

Paediatrics

Maternity

Critical care

A&E

Emergency surgery

Acute medicine

Elective surgery

Model 11D


Midwife led unit

Level 2





Model 15D


Midwife led unit






Model 3C


Level 3





Model 4A


Level 3





Model 4C


Level 3





Model 1A


Obstetric unit

Level 3





Model 1C


Obstetric unit

Level 3






▪ Frailty unit / hub included in all configurations▪ Assumes diagnostic imaging1 and pathology services exist in all models

Model 17D


Midwife led unit2


UTC only




Developing and maintaining a 24/7 consultant-led A&E was considered unfeasible from a staffing perspective

A UTC model was considered to provide insufficient access to A&E for patients

Obstetric unit

Obstetric unit

Obstetric unit

EVALUATION OF CLINICAL MODELS

87

Key differences for the remaining clinical models


▪ Frailty unit / hub included in all configurations▪ Assumes diagnostic imaging1 and pathology services exist in all Models

Model 3C 3A Model 11D Model 15DModel 4A Model 4C

PaediatricsInpatient paediatrics Paediatric

assessment unitPaediatricassessment unit

Inpatient paediatrics Paediatricassessment unit

Critical careLevel 3 Level 3 Level 1 plus critical

care serviceLevel 3 Level 3

A&E24/7 A&E with front door assessment





Emergency surgery






Elective surgery






Acute medicine






MaternityMidwife led unit Midwife led unitObstetric unit Obstetric unit Obstetric unit

Model 4A changes the model of emergency surgery

Model 4C changes the model of paediatrics

Model 11D changes the model of obstetrics

Model 15D changes the model of emergency surgery

EVALUATION OF CLINICAL MODEL

Changing this to inpatient paeds means that Model 3C becomes Model 3A is the de facto status quo for comparison

Proposal to change this to Level 3 unit on basis of limited difference in staffing required/potential for consultant presence 12x7. Would also allow for a full medical take.

88

This results in four models to do further work on, in addition to the status quo


▪ Frailty unit / hub included in all configurations▪ Assumes diagnostic imaging1 and pathology services exist in all models

Model 3A (status quo) Model 11D Model 15DModel 4A Model 4C

PaediatricsInpatient paediatrics Paediatric assessment

unitPaediatricassessment unit

Inpatient paediatrics Paediatric assessment unit

Critical careLevel 3 Level 3 Level 1 plus critical

care serviceLevel 3 Level 3

A&E24/7 A&E with front door assessment





Emergency surgery


OOH middle grade on site (cons support at York)




Elective surgery






Acute medicine

Full medical take + AAU Selective medical take + AAU

Full medical take + AAU Full medical take + AAU


MaternityMidwife led unit Midwife led unitObstetrics unit Obstetrics unit Obstetrics unit

EVALUATION OF CLINICAL MODELS

89

Questions that need to be addressed in the next phase of work

1. Emergency surgery: a. Would it be possible to staff a 24/7 consultant surgical rota?b. Would it be possible to recruit sufficient number of middle-grades to maintain a model of OOH on

site with consultant support from York?c. Even if it is possible, will this not result in as many transfers as if there was an ambulatory unit? If

that is the case, should the ambulatory emergency surgery model be adopted in more options e.g. Model 11D?

d. Which of these models are compatible with trauma unit status? What flexibility is there in how trauma unit status is defined?

2. Obstetrics and paediatricsa. Is there anything that could be done to make an inpatients paediatrics rota sustainable?b. What other innovative models of paediatrics could support neonatal care in a consultant led

obstetric service? For example a specialist neonatal nurse led model or a “block” staffing model with paediatricians from the wider region working a one week resident on call model?

c. Would it be possible to maintain a Midwife Led Unit given expected volumes? What staffing model would this require? Are there different models of MLUs? For example a pop up unit (or units) in different parts of the area?

3. Critical carea. Would it be possible to maintain L2/3 model of critical care without inpatient surgery?

These questions are not intended to assess clinical models – rather to establish a fact base in order that a

full assessment can subsequently take place.

Annex 2: Clinical workstream

Documents

Transcript of Annex 2: Clinical workstream