Report from the Shaping the Future event

There are many and significant national, regional and local issues, which necessitate change in local health services. Locally significant issues include:

· Changing population: It is expected that there will be a 14% decrease in the under 19 population and a 56% increase in the over 65 population by 2020 in the area.

· Financial pressures: In addition, the local health economy – made up of Southport & Formby PCT, Southport & Ormskirk NHS Trust and West Lancashire PCT - is forecasting an end of year deficit this year of approximately £20 million.

· Changes to Southport & Ormskirk NHS Trust: Recently, Southport & Ormskirk NHS Trust w as assessed as to whether it was fit to graduate to Foundation Trust Status, a status that all Hospital Trusts are eligible to obtain by 2008. The outcome of this assessment, which modeled the financial future of the Trust, indicated that such graduation would not be possible and that significant change needs to take place. It should be noted that an additional programme of work, Best Care Practice, is underway which seeks to improve clinical and cost effectiveness within the hospital trust and across community care. This programme also requires change in the way health and social care is provided in the future.

· Changing workforce and workforce regulations: New Europe-wide regulations to control the working lives of doctors mean that in some specialties the current model of delivery of health services is unsustainable without risking patient safety.

· The need to raise standards: The NHS is required by the Department of Health constantly to drive up standards in clinical care.

Locally there is widespread recognition that the pattern of delivery needs to change dramatically over the next decade or so in order to meet these challenges. Change is needed in terms of how and from where services are to be provided more efficiently and effectively in the future.

Review of health services across West Lancashire and North Sefton

Local health services are currently undertaking a review of where people across West Lancashire and North Sefton access healthcare currently, what the health and social needs of the local populations are, and assessing the current provision of health services against this information. The review has included a series of public consultations and the Shaping the Future event.

The aim of the review and subsequent debate and consultation on its findings is to ensure that services available for our local populations meet their needs and they have access to the highest standards of care. This means that there are real opportunities for redesigning health care services around the patient and a real need so to do given the particularly challenging financial situation locally.

Shaping the Future event

On 5^th December, the local health organisations hosted an event, facilitated by OPM, to bring together a wide range of stakeholders from the health service and its public sector partners and opinion formers in local communities to:

· Consider the implications of the forces and drivers for change operating in the national and local health and social care economy.

· Reflect on the implications of the NHS Improvement Plan, the recent delivery guidance, Commissioning a patient-led NHS and the implications for Eastern Cheshire generally and specific sub-areas in particular.

· Produce a shared view of what a modern health care system would be like and the outcomes that the Future Healthcare Project can expect from it.

· Develop a ‘blueprint of the future’ that will inform more detailed service planning, public and professional consultation and guide current investment and disinvestments decisions.

The event focused on the following key service areas, as triggers for thinking about health services more widely:

This report

This report summarises discussions held on the day. The day was underpinned by a detailed Data pack describing local and national challenges and drivers for change, and current services. We have specifically sought to avoid repeating information already contained in the Data pack.

In this report, for each of the service areas, we present a summary of the current configuration of services and some of the pressures facing them, the proposals for the service model which emerged from the event and some of the challenges that need to be addressed in implementing these proposals, which were identified by participants themselves.

1. Paediatric services

o Ormskirk DGH (this site also has an A&E and observation and assessment unit for children). The unit also provides some paediatric surgery, mainly for day cases and short stay. Children under 5 and those requiring more complex surgery are referred to Alder Hey (specialist children’s unit)

· A very limited community paediatric service has poor integration between this service and acute paediatrics. This is counter to the trend in many parts of the country where there has been a significant development of care for children outside hospital linked to the hospital service

· There is no community children’s nursing service of any kind and no specialist community nurses with responsibility for children’s care.

· As a consequence of the above, waiting times for some community paediatric services are relatively long

· There has been an increase in GP referrals, which is attributed to a lowering of referral thresholds rather than increased levels of need. This assertion will need to be tested

· A&E attendances have increased significantly – this is mainly attributable to self referrals

· There are relatively good relationships between Alder Hey and Ormskirk paediatricians but there are no formal joint appointments or shared care protocols in place. There is a Managed Clinical Network with the two A&E departments and we have shared policies.

· There are concerns that existing plans to develop a walk in centre at Southport would reduce the flow of patients through the Ormskirk A&E department, making it potentially unviable

· There are pressures on Child and Adolescent Mental Health Services across the patch.

· A number of young patients have to – or feel they have to – travel to Alder Hey hospital for emergency care, who could potentially be treated more locally.

· There is concern that if NHS providers fail to meet the demand for more community-based, accessible services, independent providers could fill the gap

Opportunities for financial savings

Participants felt that paediatric services are operating at a relatively low level and need investment rather than disinvestment. The following areas were identified as possible options for savings:

Principles underpinning changes to services

Proposed changes

Urgent care

· An emergency service for children needs to be established with paediatric A&E consultants acting as clinical leaders for paediatric emergency care for a defined population of children and young people, not all of whom would be treated in the A&E department The service could be provided by a number of hospitals but would be clinically run by one organisation

· All urgent care services from GP surgeries to walk in services to full A&E would be supported by common protocols and guidelines. The range of clinical conditions capable of being diagnosed and assessed in local centres (e.g. the Skelmersdale walk-in centre) should be expanded. Investment in advanced diagnostic skills could help retain a wider range of patients within these local urgent care services, preventing referrals on to the A&E department

· Urgent care services that are distributed across the area will need to be networked to promote information sharing and common file storage. Child protection arrangements need to be particularly robust

· Ideally it was felt that a seaside resort such as Southport with its larger tourist population should have access to urgent care for children. The costs of this could, however,well be prohibitive.

In-patient care

· There was consensus that more effective use of the facilities at Ormskirk should form the bedrock of any changes. The Ormskirk assets should be used more effectively by reducing the number of inpatient cases and increasing day surgery cases, leading to an increase in resources. This should be done in partnership with Alder Hey – with the latter only receiving cases where specialist tertiary care was needed. Indeed, the current problem of Alder Hey having a strong brand image meant that parents often took their children there rather than to Ormskirk. This led the group to suggest using the ‘Alder Hey brand’ to boost the status of Ormskirk with local people, recognising that the two paediatric departments work closely together already.

· Inpatient care for children should remain at Ormskirk for the time being, subject to the following changes:

o Reduction in the number of inpatient beds to release funds to invest in community nursing and community paediatrics.

o Exploring the scope for more flexible use of paediatric nurses between day care, A&E and in-patient wards

o Investment in a community nursing team to provide support to children at home. There may be a case for some specialist roles within the team e.g. for respiratory conditions

o Clear specification of the types of conditions that can be supported at home. The team would provide support to children with long term conditions, complex needs and palliative care.

· Hospital paediatricians would work both in the hospital and in the community once community services were established.

· There may be case for closing the in-patient paediatric facilities at Ormskirk in due course but not before investment has been made in community based services and the public and parents accept there has been a demonstrable improvement in access to care closer to home.

Ambulatory care

Community paediatric services

· There is a need to increase the number of community-based outpatient paediatric clinics, and perhaps to link these to clusters of practices, which could themselves be linked to the clinical network of paediatricians.

· There is a very low level of investment in these services at present. Additional investment in medical staffing may be needed. However, it was also felt that changes to management arrangements could help make better use of the existing resources. The following options should also be considered:

o A single paediatric team for hospital and community paediatrics across Southport, Formby and West Lancashire managed by Southport and Ormskirk Hospital NHS Trust

o Bringing the whole paediatric workforce within the management of Alder Hey. Whilst there are potential risks that the current investment in community paediatrics is diverted in favour of more acute care, on balance it was felt that the philosophy of care offered by Alder Hey was community oriented and could offer appropriate clinical leadership of paediatrics across the whole area. The advantage of this would be the potential to apply the Alder Hey brand to the whole children’s services network which should help improve confidence in the services offered whether in hospital or in community settings.

· In addition to this there was support for bringing the Child and Adolescent Mental Health Service (CAMHS) together under one management with a preferred option for this being led by Alder Hey.

There are several different locations for the delivery of community based child health services – health centres, children’s centres and a child development centre. It was agreed that there should be a review of the distribution of community health, social care and education support to see whether further use could be made of children’s centres.

Implications of these changes

· Any downsizing of the inpatient capacity at Ormskirk will have an impact on maternity services provided there. In particular, concerns were raised regarding whether the Royal Colleges would be prepared to accredit the facility if paediatric services lacked the critical mass to provide support to the maternity unit. Clearly any changes need to manage the impact on other services and particularly on maternity services.

· To ensure appropriate expert coverage of the new, more devolved arrangement for paediatric services, a clinical network of consultant paediatricians, many drawn from Alder Hey, would be necessary. These could work on a rotating basis, revolving between the main centres in the new system (Southport, Ainsdale, Ormskirk and Skelmersdale, possibly with others) as appropriate.

· There would need to be clear protocols (e.g. for when a patient should go where) and a ‘unified management approach’. The latter is particularly important in order to meet the principle of integrated services meeting the full range of needs of the community.

· The new community-based model of care might help to alleviate some of the problems associated with child and adolescent mental health services and child protection, if these are built into their design and operation.

Commentary

There was a general acceptance from participants that the model of paediatric care currently offered in Southport, Formby and West Lancashire is relatively old-fashioned and dominated (in terms of resources and emphasis) by hospital-based care, only because the community service is seriously under-resourced. There are relatively good links with the tertiary unit at Alder Hey but these have not been formalised into a clinical network.

In terms of fit between proposals for paediatrics and the other trigger specialties considered for ‘Shaping the Future’ it was striking that neither urgent care nor long-term conditions had considered children in their discussions. The group commented that this was too often the case in health care planning. There are significant issues to be addressed at the transition from child to adult services, particularly for people with long-term conditions. The main concerns expressed about the model for paediatrics came from those considering maternity services. Any move away from 24-hour paediatric cover on the Ormskirk site would mean a change in the type and volume of maternity care that could be accommodated in the hospital. There are examples in other places where maternity care is provided without 24-hour paediatric cover but participants were reluctant to accept that they could work locally.

· Review of the hospital at home pilot to identify the range of cases and impact

· Identification of any wider conditions that could be supported at home by a community children’s nursing team

· Description of the level and type of team needed to support those conditions and economic analysis of the costs and potential savings

· Contact with services in other places that have made significant progress in shifting the balance of emphasis in child health services from a hospital to community based model.

· Formalisation of the paediatric network with dedicated medical and nursing leadership. The network should encompass A&E and surgery as well as paediatric medicine. Early priority should be given to the establishment of common protocols and pathways.

2. Urgent Care

The current arrangements

Although there are A&E services, a walk-in centre and minor injuries unit, the following issues with current arrangements were identified:

· No 24 / 7 access to unplanned non-emergency care services – currently the walk in centre and minor injuries unit are not open all day every day.

· Variation in availability of unplanned care in GP surgeries: GP surgeries vary significantly in size and their ability to handle unplanned care, particularly during surgery hours. It is common that due to appointments at a practice, patients needing rapid access cannot be seen until the evening, and instead they call an ambulance and are taken to hospital.

· Range of service models and organisational differences: The large number of organisations serving the patch – i.e. 2 ambulance trusts, two social services departments, two PCTs and numerous acute trusts at some distance – means that there is a very wide range of service models as well as organisational differences. This has also led to lack of clarity for the public and lack of “joined-up” planning for the area.

· Services located outside the area: Many unplanned care services are located at hospitals outside the area. In addition, the public also travel for specialist treatment.

Pressures to change

· The low level of diagnostic support in primary care means that a lot of people go to hospital for tests when they could be done much more locally. This would be both more cost effective and better for the patient – e.g. patients attending the walk-in centre in Skemersdale who require diagnostics currently have to travel to Ormskirk.

· The transport infrastructure is poor in some parts and car ownership is patchy, particularly in Skelmersdale, rural West Lancashire and central Southport – so local solutions are needed.

· There is very poor signposting of services from one agency/professional to another leading to confusion and replication of activities between service providers.

· There are not clear messages to the public about which services should most appropriately be used when, or what level of urgency or need particular services are able to respond to. As a result of this, “too much unscheduled care happens in hospital…” Patients don’t always use the services appropriately, for example there are currently many people attending A&E at Southport who could be treated more cost effectively elsewhere.

· It was recognized that ‘It’s nice to have a hospital on your doorstep but it’s not necessarily what you need…’

Principles underpinning changes to services

· Emergency care needs to be considered in the context of ‘unplanned care’ as a whole.

· ‘Unplanned care’ should cover medical, social and nursing care that patients feel cannot wait for an appointment, and should provide better integration between health and social care.

· The framework should also consider services in terms of what care is available when – i.e. during the daytime; out-of-hours; in hospital; and, out of hospital.

· Any changes should take account of unplanned care services for children, mental health services and care for people with long term conditions: Any changes to unplanned care as a whole need to be linked in to how unplanned care is provided for children, provision of mental health services, and provision of services to people with long term conditions.

· Improved access in terms of where services are provided geographically: Whilst appreciating that the public travel now for specialist treatment, there was consensus that the public should not have to travel great distances for the majority of unplanned care.

· Simple to access: It should be clear to people where and how to access the service that they need, and it should then be straightforward to access that service. This has the potential to make unplanned care services more efficient and cost-effective, allowing for disinvestment in hospital services.

· Provide one point of access into the services (a physical building locally situated) where a range of unplanned care services – A&E, Minor Injuries Unit, out-of-hours doctors’ services and pharmacies - are accessed, ‘through one door’. This will also provide patients with the sense of security that, at the moment, is provided by A&E.

· Integrated 24 / 7 service provision: Move away from the notion of ‘out of hours’ and ‘in hours’ towards an integrated 24/7 service which meets the needs of the local population.

· Reduce use of A&E for unplanned care: Reductions in the use of A&E for unplanned care can only be achieved if there is an over-arching community service to deliver effective, appropriate unplanned care. This should include, for example, increased access to diagnostic services in the community, and directing people with minor injuries to other services.

· Different elements of care co-ordinated: There should be a triage system that means that if a patient calls for advice the person at the end of the phone should organise care for you and not just sign post—i.e. care manage.

· Improved integration between different agencies and services: Organisational and political boundaries should be simplified and there should be more integration so that patients receive integrated services.

Proposed Changes

The following proposals were made for how services should be developed in the future:

· One ‘call centre’ to triage all queries regarding where to access unplanned care – in addition to the usual 999 service – this call centre would not only be able to provide appropriate medical guidance, but would also have details of the current bed availability across the region. It was felt that this should provide a ‘human voice at the end of the ‘phone’. NHS Direct might have a role to play, linking into the principle of creating a single point of access for patients.

· The ambulance service also provides an opportunity for redesigning services. In 2006 non-urgent calls will be triaged by a health professional and many will receive advice or treatment from a primary health care professional, as opposed to an ambulance taking the patient to hospital.

· Review primary care provision with a view to creating a better service, extending what might be done during 9-5 (and maybe extended into the evenings) by GPs and their teams to avoid hospital admission. The view was that some savings could be re-directed from the selling of outdated NHS and social services premises and reviewing current deployment of GP surgeries – i.e. undertake a review and rationalise them – particularly the single handed practices that are not able to meet demand or quality standards.

· Provide an Urgent Treatment / Diagnostic Centre in Southport which would be the first physical point of contact for patients. An opportunity considered was the re-location of the planned Walk in centre for Southport General Infirmary site to the Southport District General Hospital site. It was agreed that investment in developing this service could be made by diverting monies currently going to the acute trust. By providing the Walk in centre in the Urgent Treatment Centre, alongside GP Out of Hours services and Accident and Emergency services, patients would benefit from a single triage system and direction to the most appropriate service to meet their needs. Financial savings would also accrue from the integration of services and better management of patients resulting in fewer referrals to A&E and secondary care. The Urgent Treatment Centre needs to have access to beds when patients need them.

· It was not agreed whether a similar service would be needed for both Ormskirk and Skelmersdale, although providing this in both locations would probably be the most effective way to simplify access for patients and avoid patients drifting back in the acute sector.

· Increase the flexibility in how existing resources are utilised – for example, by enabling ambulance paramedics to provide more treatment on-site rather than taking every patient to hospital. or, by training doctors’ receptionists to be able to provide basic medical guidance in order to triage patients effectively.

Implications of these changes

The changes would also need to link closely to any changes to services provided to people with long-term conditions.

Commentary

The groups found it difficult to specify the exact arrangements currently provided as there is not currently a shared understanding of what services should be defined as ‘urgent care’ as opposed to ‘unplanned care’. There was also disagreement in identifying unplanned care in terms of in-patient, outpatient and ambulatory.

There was also lack of clarity between healthcare professionals about what services are provided in the Minor Injuries Units and the Walk in centre. This lack of clarity amongst service providers currently translates to service users, who are not clear about which services are most appropriately used when, leading to people using A&E as a ‘default’.

There was a willingness to divert funding away from acute services to support more unplanned care services in the community, but further developing these services will only be cost effective if people use the range of unplanned care services more appropriately.

3. Long-term conditions

The current arrangements

Long-term conditions include diabetes, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), arthritis, dementia / neurological conditions, mental health and clinical obesity.

· Southport District General Hospital – urgent care; in-patient medical; intermediate care

· Hospital based cardio rehabilitation (with dietetics and heart failure nurses).

· Social Services Day care (provision currently under review), e.g. Brookdale Resource (result of partnership agreement with Sefton Social Services) is a community service for assessment and day care for older people with functional / organic mental health problems; Burscough day care.

· Outpatient clinics run by consultants in social services based facilities, for Parkinson’s / TIA clinics.

· Re-enablement (short-term homecare provided by social services, if after 6 weeks the patient still needs personal care, then assessment and homecare are purchased from private sector)

· Community services, e.g. specialist nurses (diabetes/ respiratory) / District Nursing / Community Matrons (yet to come into operation) / healthcare assistants

There are moves towards increasing community based care (with the introduction of community Matrons) but these have not been fully realised yet.

· Aintree for rehabilitation for amputees, renal / dialysis, strokes and coronary care.

· Patients on East of patch may be treated in Wigan for A&E strokes, orthopaedic and trauma care.

Pressures to change

· Changing demographics: There is an increasing population with long-term conditions, both due to an aging population and an increasing incidence of long term conditions in younger people. More complex patients can now be maintained at home. At the same time there is a shrinking pool of informal carers.

However, information management and local public health data on long-term conditions is better than it has ever been - in both PCTs Long-term Conditions Groups are trying to use this data to understand local needs and plan services accordingly (i.e. to promote best practice and reduce hospital admissions). It will be increasingly important to know where the ‘clusters’ are for long term conditions in order to target services / awareness raising effectively.

· Services that are commissioned for these patients are not well promoted and patients are often not aware of the most appropriate place to be treated, leaving some services under utilised.

· The healthcare system is currently focused on dealing with crises as they arise, rather than prevention, early detection and on-going management of long-term conditions.

· The system is not patient-focused, as people with multiple conditions are seen in multiple locations, and patients have to visit different places for similar tests, both leading to unnecessary travel, inefficiency and confusion.

· At present, many services associated with the management of long-term conditions (e.g. out-patient, diagnostic, rapid response team, intermediate care, social services day care) are centred on in-patient acute facilities (e.g. Southport District General Hospital). Follow-up appointments that could be carried out in primary care are generally held in acute settings, and many patients see a consultant for appointments when they could see another health professional.

· There is no single point or person co-ordinating a patient’s care and information flows within and between organisations are poor.

· There are pockets of good practice, but they are not consistently applied across the patch i.e.,

o Mornington Road, Falls – consultant visits to deliver outpatients clinic (Parkinsons)

o There are discrepancies between West Lancashire and Chorley & South Ribble in the provision of adult physio, District Nursing and Neurological rehabilitation.

Principles underpinning changes

· There should be a strong focus on prevention (through public health initiatives, education and information).

· Whilst the bulk of people with long-term conditions are older people, the design of services in the future must take into account children’s and adults’ needs.

· Routine care of people with long-term conditions should be differentiated from non-routine care – routine care should be at the point closest to the patient; non-routine care may be further away.

· People should be treated at the lowest appropriate level of clinical intervention.

· The first point of contact should be able to signpost the patient through the system and effectively connect up with the range of providers / professionals involved in delivering that individual’s package of care.

· Care needs to be delivered as close to home as possible (or place of work/family etc)

· Services need to consider ‘the patient as a whole person’ – i.e. design a package of health and social care.

· Patients should be offered choice in terms of how they access services (variety of locations / route ways / professionals involved) and more vulnerable groups should receive advocacy support to enable them to make informed choices.

· Healthcare should be available out-of-hours to suit the needs / lifestyles of individuals (although effective management of conditions should mean fewer crisis phases and so fewer out-of-hours acute incidents)

· There’s a financial incentive to prevent the local health economy going further into debt (this is secondary to, but not necessarily in conflict with the above)

· Services need to support the mental health of people with long-term conditions.

Proposed changes

Prevention of long term conditions

Although the impact of some public health initiatives takes a number of years to be realised, there should be increased investment in these initiatives to prevent people entering the ‘high-risk’ groups, through

o Education and awareness raising in community settings, e.g. schools, supermarkets;

Early identification of long term conditions

Services need to be structured to support the early detection of long-term conditions (e.g. diabetes) so that management packages can be implemented before patients have a crisis / acute incident and are admitted to hospital. These arrangements need to recognise that many older people are unaware of what support might be available to them. Proposed arrangements are:

· Education of the public to know what options are available and to manage their expectations (i.e. what are the alternatives to the GP and hospital).

· Extending the role of those already working with high-risk groups – e.g. the community warden service, Meals on Wheels, lunch clubs and other voluntary agencies who would be able to refer on for clinical diagnosis.

· More widespread community based screening, targeted at high-risk groups (e.g. pharmacy based diabetes screening – ‘high-street’ setting in places such as supermarket pharmacies, that provide a suitable environment for protocols to be developed).

· Extending the role of specialist nurses and health visitors to diagnose, as they are able to although this role is currently primarily undertaken by GPs.

Maintaining the health of people with long term conditions

· Establish local integrated primary care teams across the patch. Tthese should have appropriate skills mix to provide support on a range of long term conditions and be able to support people with multiple conditions, and should include in-put from GPs, specialist / community based nurses, practice based physio, healthcare assistants, social services, homecare providers, voluntary sector, and should relocate specialist nurses (diabetes/ cardio rehabilitation) from hospital into a community setting. The teams should also include social services. These teams should:

o Provide the patient with a case manager / community matron model of care, that gives a ‘whole person approach’, integrating signposting, advocacy, primary / secondary care, and social services. This person need not necessarily be a nurse.

o Design patient-centred and locally delivered packages of care focused on condition management;

o Help with swift and successful rehab / re-enablement following an acute phase, e.g. through Community Health Mentors.

It was noted that, for example, clinical guidelines are that hypertension patients on 3 or more drugs should be under the care of the consultant, and this represents 60% of hypertension patients. However, this could be addressed through the proposal below for extending the range of services provided in community locations.

· Extend the range of services currently provided in community locations – there are a number of quite large health centres in the patch (where GPs are based), which have the potential for delivering more services than they currently do. These should be strategically placed geographically (most communities have a suitable location in the larger villages) and the additional services provided might include:

o GPs with specialist interests providing some out-patients services currently provided in acute settings;

o Where a consultant out patient appointment is necessary, consultants providing outpatient clinics in community settings;

o More input from a range of voluntary services, such as Age Concern, that could provide advice and support about broader issues than the purely clinical.

· Extend the range of services currently provided through community rehabilitation facilities such as Mornington Road – e.g. these could be resourced with community nurses and support community out-reach.

· Provide services at home where possible, for example, at home diagnostic services (especially for older people) supported by healthcare assistants / nurses.

· Explore scope for ‘one-stop-shops’ (either locality or condition based) – e.g. a diabetes one-stop-shop centre would conduct blood / glucose tests, eye screening and podiatry all in one place

· Encourage and enable individuals to self-manage their condition (e.g. Expert Patient Programme)

· Under these arrangements, patients should still have rapid access to specialist professionals where necessary to prevent them seeing A & E as the only entry point in an acute phase.

Managing acute exacerbations

· Essex Ambulance Service has details of patients with long-term conditions, and an emergency care practitioner who visits the patient to carry out an assessment and refer on as appropriate, deals with calls from these patients.

· One third of people admitted to hospital at night have long-term conditions and are admitted because there is no alternative provision for them in the community. If these patients could be cared for in the community this would reduce the pressure on consultant time.

Implications of these changes

Ways of working

· If more practitioners from different agencies are to be involved in the identification and management of people with long term conditions, then there need to be clear patient pathways for these people to be referred in to.

· Multi-agency and increased multi-disciplinary working will require the systems, including IT, protocols and staff training to support information and record sharing.

Workforce implications

· Increased identification and support of these patients by non-clinical practitioners ‘on the ground’ (e.g. social services / healthcare assistants / voluntary sector workers) will require significant workforce training and development.

· More nurses and GPs with specialist interests will be needed to deliver outpatient follow-ups more locally.

· However to do this primary care practitioners must be brought on board, and often there is resistance from practitioners (GPs, pharmacists, dentists, ophthalmists etc) who are already overstretched - professionals will have to be flexible if the patient is to be put first.

· In theory fewer consultants will be required to deal with acute phases / out-patients (although this may be counter-balanced by the increasing incidence of long-term conditions).

· Consultants will have to change current patterns of work, to provide more services in the community, or could even be community-based, providing in-reach to hospitals.

· There needs to be more partnership working between health and social services – maximise limited funds and staff by pooling them where appropriate (e.g. for rehabilitation and re-enablement)

Financial implications

· Savings could be made through lower use of A&E, lower occupation of beds and lower ‘hotel’ costs for this group of patients if they are maintained in the community.

· However, a reduction of 1% or 2% of patients going through acute services would not release money.

· If patients were treated at the lowest appropriate level of clinical intervention, the cost of clinical time would be reduced.

· The reduced use of hospital services would potentially reduce prescribing, and hence costs.

· More services provided in the community will mean fewer DNAs (did not attends) for hospital out-patients due to transport difficulties, leading to cost savings.

· However, even if it is possible to maintain a greater percentage of these patients in the community, the increasing incidence of long-term conditions means that it is unlikely to be possible to release resources and specialists from the treatment of these patients.

Other implications

· If there is a more co-ordinated approach to the management of people with long term conditions, it is likely that nurses will identify social care needs, but there is currently very little available that they can access.

· It will be important to sustain existing services whilst building up alternatives in the community.

· If out-of-hours care were managed differently GPs would be freed up to increase their focus on the management of people with long term conditions.

Commentary

There was a general acceptance that too many services are currently provided in acute settings and by consultants that could be provided in community settings and/or by other health professionals. However, the proposals carry significant implications for the workforce, in terms of training and deployment, at a time when recruitment and retention are challenging.

There was a strong theme amongst participants that people with long term conditions need to be supported through a range of interventions, not just clinical, and that this implies commissioning of more services from the voluntary and community sector that can support people to maintain their own health.

It was difficult to identify clear savings from the proposals as it is not clear whether investing more in maintaining people’s health through community services will deliver savings, or simply offer an alternative model of service provision. Furthermore, the growing population with long-term conditions means that it is unlikely to be possible to reduce the resources required to support this group.

4. Maternity care

The current arrangements

Definition of terms

§ Antenatal complications – (under 16 weeks gestation – classed as gynaecological emergencies; over 16 weeks gestation – classed as obstetric emergencies)

Termination of pregnancy was considered to be an outpatient service but excluded from the discussion.

Community-based midwifery team accessible from GP surgeries but managed by acute trusts.

There was some discussion about what comes under this title in maternity services. Some delegates felt that the term ambulatory may not apply to any maternity services. These are not defined as outpatients as women may need to be at the hospital for at least half a day

How services are provided

The Southport site has Midwifery led Unit (currently closed), which averages about 150 births per year and is therefore felt to be both clinically and financially unviable.

Ormskirk District General Hospital is increasing the number of births per year to about 3000 births and has a good clinical reputation. The Women’s and Children’s Unit opened as recently as October 2004. Recent closures of other local hospitals have consolidated the position of Ormskirk as the only place where the following services are provided and co-located (“full service provision”):

o Maternity, including Early Pregnancy Assessment Unit and Pregnancy Assessment Unit

The site is also the local hub for most other community-based services and educational facilities are good.

There are also some people travelling out-of area for their maternity care, and other ‘full services provision sites’ are:

· Liverpool Women’s Hospital (LWH): services include ante natal, a neo-natal unit, and gynaecology. The hospital also provides tertiary care and difficult pregnancies are sent to LWH but a high proportion of women also choose the LWH for delivery. There is also a strong clinical relationship between Ormskirk and Liverpool. 50% of those living in Formby choose to go to Liverpool Women’s Hospital. and there are also plans to expand.

· Wigan (full service including neo-natal unit, Gynaecology). There may be plans to expand Wigan

There are a range of other complementary services including Social Services (mental health) and 2 Sure Start programmes.

Home births are below the national average. There is an “aqua-natal” service in the area.

There are a number of GP practices in the area that are fairly evenly spread across the main population areas. Currently 20% of midwives are based in the community and 80% in maternity units.

Pressure points

· There is concern that it will be difficult for Ormskirk District General Hospital to contain costs within the national tariff.

· There is national guidance (from the Royal College of Obstetrics and Gynaecology), which outlines 3-4000 births per year as a minimum level for unit viability. The Ormskirk site currently handles just under 3,000 births per year.

· Ormskirk needs to operate at full capacity of approx. 3,500 births a year, an increase of 500 from the current level of approximately 3,000. However, the Liverpool Women’s Hospital remains a popular choice and could affect Ormskirk achieving capacity levels.

· The locality faces an overall falling birth rate but this is not evenly spread. There is therefore an increasing dependency on out of area residents choosing the Ormskirk site (these currently account for round 25% of the births at Ormskirk).

· There’s a shifting perception about what “local” means, both for residents and for local GPs. For the latter the proposed changes to the Strategic Health Authority boundaries may encourage local GPs to look further afield (especially north) in referring local residents to services.

· People are largely able to choose where they go for maternity services, providing they can be safely clinically cared for within their preferred service, and patient flows cannot be directed by PCTs.

· There are currently no independent sector maternity providers in the area but this is thought to be a real possibility in the future, which would further threaten Ormskirk’s ability to attract a critical mass of women to give birth there.

· Transport infrastructure is particularly poor and inaccessible due to cost for many local residents. This therefore potentially restricts access to services.

· Nationally there are higher numbers of older women giving birth, where birth can be complicated and the child may have special needs and therefore require the back-up of a specialist unit.

Principles underpinning changes to services

· Sustainability: changes must contribute synergies to the local portfolio of services.

· Clinical Safety: services must meet standard good practice and the requirements of the National Service Framework.

· Maternity services should be provided as close to home as possible and should be as accessible as possible.

· Women should be provided with the information and support to choose the service they would like, within the bounds of clinical safety.

· User-focused: services delivered in the community at a place and time convenient to the user.

· Changes must be considered in the context of maternity services across the North West region.

· Changes should strengthen and maintain links with a tertiary level care provider – i.e. Liverpool Women’s Hospital.

· More services provided in the community, rather than a hospital environment – recognizing that pregnant women are not ill.

· Provide more midwife-led care, as this is popular with women, and only 35-40% of births require medical intervention.

Proposed Changes

· The maternity / midwife led unit at Southport should remain closed on the basis that it does not satisfy several of the principles underpinning change (particularly relating to unit viability (RCOG guidance, clinical safety).

· The current service configuration centred on the Ormskirk site should remain as a central hub within an acute setting, but supporting a greater range of community (midwife led) provision.

o To “unbundle” these services was thought to be difficult given the cost of equipment and recent capital expenditure on the site, and the expected loss of experience that would result if one professional group were to be de-coupled from maternity services.

o There were concerns about capacity to deliver more consultant sessions in community settings.

o There were concerns raised about public support for the continued closure of the Southport MLU. Specifically, that the transport infrastructure would be sufficiently developed to support a greater centralisation of services.

· One group proposed the development of a midwifery led unit in Skelmersdale where there is a growing need due to comparatively high rates of teenage pregnancy and increasing housing. However, the cost (approximately £15m) was felt to be prohibitive, and services at Ormskirk are accessible from Skelmersdale.

· There is the potential for more services to be delivered within the community. Specifically:

o Consultant clinics/ episodes being held in community settings. This was felt to be viable for low and medium risk cases.

o Midwifery led care (as compared to GP led maternity care) in the community, but whilst retaining the Ormskirk site as a central hub of expertise.

Implications of these changes

The small number of births at Southport Midwifery Led Unit would be expected to move to Ormskirk.

However, there is a need to evaluate the demand for maternity services in the future, as it is likely that services will need to attract women from other areas to utilise current capacity and ensure services are sustainable. It is estimated that 25% of births will need to be to mothers from Maghull, Litherland and Kirkby wider.

The pressure to attract women from out of area and the centralisation of services at Ormskirk increases pressure to improve transport links. Suggestions for addressing this included: shuttle bus, travel vouchers, home start volunteers with car, and other voluntary sector options.

Commentary

The Ormskirk site and services have a good reputation and there are good links with the Liverpool Women’s Hospital, which manages difficult pregnancies.

However, the model of care is dominated, in terms of resources and emphasis, by hospital-based care. The comparatively low number of home births, and the lack of a midwifery led unit on the patch following the closure of the Southport unit, although participants recognised that this was in line with the type of care that women often prefer, reduces choice further. There was general agreement that the predominant model of care needed to be shifted away from consultant-led to midwife-led, but participants were reluctant to significantly change existing arrangements.

In order to protect the Ormskirk service, more women need to be attracted to the service from outside the area, presenting a significant challenge. It will be important to review how realistic this might be.

As discussed by participants, it is clear that maternity services for Southport & Formby and West Lancashire cannot be developed in isolation from the region as a whole, and further work is therefore needed to explore and respond to this broader context and, in particular, linking it to the Maternity Services Review currently being undertaken by the Cheshire and Merseyside Strategic Health Authority.