Redditch and Bromsgrove Primary Care Trust

The above review paper has been issued in public by the Worcestershire Hospitals Acute Trust (WAHT) as a pre-consultation document. The following provides a commentary for PCT Board members to consider the implications of the paper.

The PCTs role

The primary obligation of the PCT is to ensure that commissioned services meet the following criteria, irrespective of provider:

• appropriate to the health needs of the local population(s);
• fair and equitable;
• clinically effective and subject to robust clinical governance arrangements;
• part of agreed care pathways which deliver best clinical practice
• cost-effective, offer value for money and are affordable within the financial resources available.
• ensure delivery of national standards and targets.
• Delivered in physical facilities that are fit for purpose and effectively utilised.
• Modernised in line with the '10 High Impact Changes'.

Our secondary obligation is to ensure survivability of local services. Although we would wish services to be provided as close to home as possible, in the case of Redditch and Bromsgrove, this gives us a choice of providers including those in Birmingham and Warwickshire, as well as WAHT.

1. Process

1.1. In general, the Finnamore process has been well thought out. We are particularly pleased to see the considerable patient and public involvement that the trust is undertaking.

1.2. We lack detail on the information sources used to model activity and resource implications, therefore cannot be assured of the robustness of these. Any data that the Trust is gathering now needs to be shared with us prior to any further documentation being made available publicly. We note, however, that the PCTs' capacity plans have not been used in determining future activity levels.

1.3. References to the Princess of Wales Community Hospital (PoWCH) need to be checked and approved with us prior to any documentation, as the current references are inaccurate.

1.4. Throughout the process, the review has taken a 'county-wide' perspective. This perspective does not reflect local issues, e.g. poor daycase rates for Redditch and Bromsgrove PCT, or realistic choices; e.g. Redditch and Bromsgrove people may choose healthcare in Birmingham over healthcare in Worcestershire, particularly if services are moved from Redditch. This latter issue is over and above repatriation issues which are (sensibly) considered unfeasible.

1.5. There is little attention paid to 'free choice' which may result in more activity being undertaken at other providers, particularly independent sector providers - both for elective work and diagnostics. This is clearly linked to recent capacity planning exercises.

2. Conclusions from the Diagnostic Stage

2.1. It is clear from the review that Worcester Royal Hospital (WRH) is the least financially viable of the three sites yet the options are centred on development of this site rather than the other main site at Redditch, presumably because WRH is a PFI hospital. We consider that the option to expand Redditch should be considered.

2.2. The report states that the Worcestershire Health Community spends less on healthcare than the national average and also less than peer (shire) counties - presumably because the national capitation formula does not allocate Worcestershire the same types of funding levels. The health community also spends proportionately less on secondary care and more on primary and community care - this is borne out by secondary care access rates, which typically are lower than 'peer' communities. This suggests, however, that those patients admitted to hospital are highly dependent. It may also suggest that all those patients that can be offered community care are already receiving community care. In either case/both cases, this may limit the aspiration to reduce length of stay and care for more people in a community setting.

2.3. Mention is made on several occasions that 'no assumptions have been made with respect to semi-variable costs' - and yet there may be significant scope to reduce these costs through the reconfiguration of multi-site services such as pathology, pharmacy, HSDU etc - which do not appear to have been considered.

3. Menu of Options:

3.1. Productivity

3.1.1. The ability to achieve 'upper quartile' performance across all specialties on a three-site trust has to be questioned. Most trusts will achieve this in some but not all specialties and use very efficient specialties to subsidise less efficient specialties. If the Trust focuses purely on the most efficient specialties then some services are likely to be lost from Worcestershire.

3.1.2. Achievement of the level of savings required is predicated on these productivity improvements. Even if upper quartile length of stay (LoS) in all specialties is achievable, the level of savings identified seems very high/over stated. It would be helpful to have sight of the detailed supporting financial figures. It would also be helpful to know of any other organisations that have achieved these levels of productivity and how they have managed it, and the impact on out of hospital services.

3.1.3. Equally we would wish to understand current productivity, at specialty level, more fully as there are a variety of views on current performance and a lack of data to confirm or deny any one of them.

3.1.4. None the less, there would certainly appear to be scope to improve on current productivity levels and a more realistic target might be to achieve national average LoS, supplemented by a more rigorous review of theatre utilisation, skill mix etc. It should be demonstrated that all of the opportunities to improve productivity by implementing the '10 High Impact Changes' have been pursued, e.g. day case usage, which we know to be variable across the Trust.

3.1.5. There appears to be no assessment of the cost impact/capacity for the expected increase in out of hospital care, or of the loss of income to the Trust under the new Payment by Results (PbR) financial regime e.g. for reductions in excess bed days.

3.1.6. No mention is made of the patient choice agenda and the possible impact this may have. On the edges of the county, patients are quite likely to choose out of county providers rather than WAHT.

3.1.7. The impact on bed numbers has only been considered under the most optimistic 'peer group upper quartile' model, and therefore the scope for reconfiguration, if any, cannot be determined for less ambitious reductions in beds.

3.1.8. 90% bed occupancy (greater use of the community hospitals and intermediate care) was put forward in 'Investing in Excellence', but has not been achieved. We would like to understand why the Trust feels it is achievable now.

3.1.9. Any attempts to improve productivity through reduced lengths of stay/admission prevention cannot be viewed in isolation and need to be part of a whole system approach to the management of both scheduled and unscheduled care. Existing community care systems are largely geared up to respond to current productivity levels. Alteration of productivity e.g. shortening length of stay will alter the level of community support required. Whilst there may be some scope for dealing with marginal improvements in productivity, any step change in performance will require a corresponding increase in investment in community/primary care services both in terms of additional community nursing capacity and support from general practice and also social care. We cannot find any reference to this additional cost within the paper. We are willing to work with the Trust on looking in detail at the patient pathway for supporting highly dependent patients and early discharge where appropriate.

3.1.10. Furthermore, the availability and use of community beds will be an important element of patient flow through the system. Any proposals which affect community hospital provision must be considered in this context with PCTs.

3.1.11. Impact of these changes is not just on NHS organisations but also on Social Services. Social Services signup to the proposals together with a recognition that there may be increased community and social costs of implementing them is key. Further modelling about the impact on both NHS community services and social services workload is necessary to save simple cost shifting.

3.1.12. There is no guarantee that any savings made would be reinvested in the acute sector.

3.2. Re-configuration - Simple

3.2.1. It is likely that some activity would be lost under the simple reconfiguration option (particularly obstetrics to Birmingham Women's Hospital) as local individuals may not want to travel to Worcester.

3.2.2. Considered as stand alone services, rationalisation of maternity and paediatric services to one site would be sensible from a clinical safety perspective. However high clinical risk per se should not be the reason for single site working, if dual site working can be made safe and there is demonstrable need.

3.2.3. The 'domino' effect needs to be considered - A&E without paediatrics is unsafe. Combining the two A&E departments is, we consider, unfeasible (see below). Transfer of paediatric trauma from the north of the county to Birmingham is also, we understand not feasible. Hence we believe that paediatrics and A&E should remain at the Alexandra.

3.2.4. We must all be clear about the concept of a 'midwife led maternity unit'. NICE is currently reviewing the area of stand-alone midwifery units. If this is a unit caring for home delivery risk patients, then we would question whether 700 births is realistic (300 may be nearer the mark). If it is a midwifery led unit dealing with higher risk births, then, until NICE guidance is available, the PCT needs to consider if we would only support it being run alongside a consultant led unit. An alternative provision of obstetric services might be through Birmingham Women’s Hospital, allowing excess Birmingham births to be redirected to the Alexandra, and rotational/split site work. This might result in a viable Alexandra based site offering services to Birmingham residents, if the option of centralisation of services to WRH cannot be taken forward.

3.2.5. Similarly, could support for a paediatric service at the Alexandra also be sourced from Birmingham Children's Hospital or other trust?

3.3. Re-configuration - Complex

3.3.1. Costs incurred in changing services have not been taken into account.

3.3.2. The two A&E departments across the county are of similar size, and could not be combined without expansion of facilities.

3.3.3. Without medically staffed A&E services, trauma could not operate out of the Alexandra.

3.3.4. Without paediatric support, A&E would be significantly compromised.

3.3.5. 70% of emergency admissions to the Alexandra are through A&E. Shifting this to WRH may simply add pressures to transport systems, which would have to be funded through the health economy.

3.3.6. Almost certainly some minor injury facility would be required at the Alexandra. There is no mention of these costs within the paper.

3.3.7. Redditch people would be disadvantaged in the time to access A&E services if moved. Work would most definitely transfer elsewhere, and with it, under PbR, would go resources.

3.3.8. Out of Hours Services (OOH) and A&E - there appears to be a connection but there is no explanation. As a PCT, we would welcome the opportunity to explore in greater detail the closer alignment of out of hospital care, but this needs to await the forthcoming white paper.

3.3.9. We are unclear of the benefit of moving cancer surgery to WRH - is this associated with the critical care beds? Not all cancer surgery will need this degree of support, and indeed there is probably greater overlap with elective work (which would presumably remain at the Alexandra) than with critical care.

3.3.10. There are access implications of having just two chemotherapy suites - which area would lose out? Ill people requiring regular chemotherapy will not want to travel across the county to access it. It also against of concept of local cancer units as detailed in the national Cancer Plan.

3.4. Site rationalisation

3.4.1. No discussions have taken place about the PoWCH site with the PCT. Lickey Ward is not the 'trust's ward'. It is owned, managed and fully funded by the PCT - we buy the consultant input from the Trust. Hence there would be no savings accruing to the Trust from altered use of this ward.

3.4.2. We note that PoWCH has been singled out as the only community hospital affected by this proposal. We believe that at least part of the solution to this problem lies with improved working of all the community hospitals and services, not just those in Bromsgrove.

3.4.3. Any proposals that affect community hospital provision must be considered in the context of the out of hospital care white paper.

3.4.4. Any changes to PoWCH must also be considered within the context of the whole hospital and the full range of services provided from that site, which go well beyond that of the ward and outpatient department mentioned in the Trust paper.

3.5. Repatriation

3.5.1. There is a heavy focus on repatriation of ENT (currently a specialty struggling to meet waiting times). The ENT business case did not reveal a £100K saving from repatriating activity from Birmingham.

3.5.2. Options to repatriate activity also need to be rigorously costed to ensure the anticipated additional income is in excess of any additional costs incurred. It may well be more cost effective to avoid repatriation of any complex activity - and therefore avoid the cost of additional investment in equipment/facilities that may be required.

3.5.3. Reconfiguration options may result in activity being referred to other providers - particularly from GP practices located in Bromsgrove, Rubery and Wythall, and also from Evesham - and a range of scenarios need to be modelled to test the sensitivity of each option against reduced levels of income.

3.5.4. Options to expatriate activity should also be considered if reductions in cost could exceed the loss of income.

3.5.5. The quality of service being provided is critical to successful repatriation. The Trust will need to demonstrate to local GPs and patients that their services are of a significantly higher quality than those elsewhere if this strategy is to be successful (and currently, Birmingham providers have much shorter waiting times for treatment).

3.6. Demand Management

3.6.1. With respect to demand management and the reduction in outpatient follow-ups, confirmation is needed that the stated saving is net of the reduction in income under PbR. This should also be considered in respect of the impact of non-elective admission avoidance schemes planned by PCTs and we are willing to share our work with the acute trust if this is helpful.

3.6.2. We believe these are reasonable assumptions on follow-up rates but will there be a cost elsewhere in the health economy or will practice based commissioning provide sufficient incentive to cease inappropriate follow-ups and get GPs to do the work?

3.6.3. Should the PCT do some work on ‘low-priority’ treatments and stop doing these? These are likely to be the ones the Trust generates a surplus on, however.

3.7. Cease trading in unprofitable activity

3.7.1. See previous comment on loss of current services in Worcestershire.

3.8. Improve income recovery

3.8.1. We are pleased to see that this is treated cautiously and recognises the fact that this will merely shift the problem out of the Trust and into primary care. Other services will have to be ceased in primary care to pay for this activity. This in turn is likely to result in greater pressure on the Trust, making productivity savings more difficult.

4. General Comments

4.1.1. It would appear that most of the financial pressures come from the WRH site, rather than the Alexandra or Kidderminster.

4.1.2. The document is not a health economy view of the problem, rather an acute view. Many of the proposed solutions have knock-on effects in community services, and may require additional funding. This aspect does not seem to have been considered.

4.1.3. Have likely future trends, particularly an ageing population and greater expectations, been taken into account in modelling these proposals?

4.1.4. Have the impact of new policies, particularly Patient Choice, Practice Based Commissioning and Payment by Results been adequately thought through and the implications modelled?

4.1.5. The potential impact on other providers also needs to be considered - could they cope if, as a result of these changes, work flowed into Birmingham (e.g. paediatric trauma to the Children's) or Cheltenham?

4.1.6. We would urge the Trust to consider the impact of Foundation Status, e.g. ceasing loss-making activities. It may be that starting from this perspective enables more sensible long term rationalisation decisions.

4.1.7. We are aware that professional opinion from local GPs is not in favour of some of the proposals being put forward, particularly the impact on community services. Positive engagement with GPs will be imperative in taking this work forward.

4.1.8. Reconfiguration, other than on the grounds of clinical safety, should be a last resort, not a first resort, particularly if there are significant efficiency savings to be made through smarter working practices.

4.1.9. Much more detailed work is required on the options produced so far (including validation of the data).

4.1.10. We are concerned that many of the proposals are those we have heard before but not successfully delivered. Have more radical solutions been considered, and if so why have they been discarded?

5.0 Conclusions

In conclusion we believe:

• Productivity must be addressed. However there appears to be over emphasis on increased productivity as a means of making financial savings, with over optimistic productivity targets, against the background of a Trust that has failed to respond to challenges about productivity in the past. Equally, if relatively greater proportions of funding have historically gone into community healthcare schemes then the ceiling for community healthcare may have been reached, or alternatively admitted patients maybe more heavily dependant. Either or both of these factors make increased productivity even more of a challenge. Medical leadership will be key to delivering productivity gains. We also note that productivity gains may only be possible with reconfiguration, but we need to understand the rationale for that more fully.
• Service reconfiguration, certainly at a 'simple' level, provides a relatively small proportion of savings. It is however likely to be by far and away the most controversial. Management time maybe better focused on the larger gains to be made from productivity (no matter how difficult), rather than split between this and the highly politically charged reconfiguration issues.
• Impact on community services must be thought through, as additional funding may be necessary to ensure community services can meet the additional demands placed upon them. Any changes to this would need to be considered in the context of the forthcoming White Paper.
• This work must take a whole systems approach. Shifting costs from the acute sector to the community will not solve this problem long term.
• The impact of new policies particularly payment by results, choice and practice based commissioning must be thought through and, if possible, modelled, as should the impact of Foundation Trust status.
• Fundamentally there is insufficient money in the system to support the high infrastructure costs in Worcestershire. However, we accept that additional funding via the national formula is not and will not be available, and that there are fixed points in the current infrastructure e.g. the PFI hospital. Given this, more radical solutions than those proposed are required. We have also mentioned working with Birmingham providers to support certain services already. The end of that continuum might be for a Birmingham Trust to provide services at the Alexandra Hospital, on a hub and spoke basis. These options will need detailed and careful working up.

As such we would strongly encourage the Trust to look first at the '10 High Impact Changes' as a method of improved productivity and to devote all management resource to the implementation of these changes. We will be happy to then work with the Trust on improving the management of patients through the system, in the light of the forthcoming white paper.

At this time, we believe that the reconfiguration options would detract from the work that needs to take priority and would benefit from more careful thought and work up. We also believe that further options involving other providers need to be included in the review process.

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