Whole systems planning

1. Whole systems planning Jane Austin Future Healthcare Network Jane.austin@nhsconfed.org January 2003

2. About the Future Healthcare Network (FHN) Context Changing the shape of the system Changing the organisation of hospitals New planning system Conclusions Summary

3. UK FHN Network Information Authority Major Contractors Group DOH Policy Unit EPR Impact of IT on design Working with private sector Output specs Urban regeneration PPP Acute Strategy Maternity/Paeds changes Future Healthcare Network Royal Colleges Acute Reconfiguration Streamlining procurement process PFU Information exchange Redesign Changing workforce Accommodation Training implications Modernisation Agency University Hospitals Network Sustainability Design quality Design quality Building processes NatPaCT CABE Prince’s Foundation NHS Estates

4. Overseas FHN Network European property network Australia New Zealand Information Authority Major Contractors Group DOH Policy Unit PPP Acute Strategy Maternity/Paeds changes EPR Impact of IT on design Working with private sector Output specs Urban regeneration Future Healthcare Network Royal Colleges Acute Reconfiguration PFU Streamlining procurement process Information exchange Redesign Changing workforce Accommodation Training implications Modernisation Agency University Hospitals Network Design processes Design qaulity Sustainability Design quality CABE Prince’s Foundation NHS Estates USA

5. Role of the Future Healthcare Network Innovation Implementation Policy development Trusts NHS Confed

6. Innovation Implementation Policy development Support for changes in the NHS System configuration Planning and PPP Environmental design Re-Design & clinical pathways FHN Workforce change Finance Planning and PPP Technology change

7. Whole system thinking Modernisation Agency NHS Estates Acute trusts DOH policy unit PCTs NPDT NatPaCT New models of care, Changing workforce, ICT, Building design GP Premises and GP contract More care outside hospital. LIFT, Walk-in Centre,One stop shops, DTCs Social care Hospital Network PCT Network Whole system planning Best practice across all PCTs Policy Development Best practice across all acute trusts

8. No major building for 10+ years Knowledge base and skills out of date, fragmented Patient safety, staffing pressures New political imperatives New methods of building and procurement New culture Context

9. Centralisation of decisions: historically unbalanced Affordability Workforce Patient safety Patient experience Centralisation Decentralisation

10. … but now rebalancing ... Workforce Affordability Patient safety Service delivery Patient experience Centralisation Decentralisation

11. … and influenced by new developments IT opportunities - remote diagnosis Training flexibility High tech equipment Service delivery Affordability Workforce Patient safety Patient experience Role changes Clinical networks Centralisation Decentralisation

12. So what is changing? Organisation inside hospitals Shape of health system

13. Changing the shape of the health system

14. Chaotic health system GP Outpatients Radiology Lung function Mortuary Home Haematology Endoscopy Emergency Dpt Ward Medical assessment unit ? Theatre Pathology

15. Components of the health system Specialist Tertiary hospital 500k pop District Hospitals (250k pop) Local care centre(s) 50- 100k pop Decentralisation of care GPs 2-10k pop

16. Main access Specialist Tertiary hospital 500k pop Option 1 – Traditional model Complex cases Medically fit for discharge Selected access District Hospitals (250k pop) emergency care Local care centre(s) 50- 100k pop Medically fit for discharge or for convalescence elective care Social care

17. Specialist access Specialist tertiary hospital 24/7 Option 2 – Access at all levels Local Emergency Local access Local elective: Complex cases +ICT Local emergency care (BeCAD) Main access Local elective care (ACAD) Critical care Medically fit for discharge ?16/7 Local access Local Care Centre(s) Social care

18. Specialist tertiary hospital 24/7 Main access Option 3 - Local access + information highway Local BeCAD Local ACAD: Strong ICT links specialist ambulatory care Main access BeCAD: Local emergency care ACAD: Local elective care Critical care ?16/7 Strong ICT links Local Care Centre(s) Social care Local access

19. Conclusions about redesigning the system • Different models to fit local needs • Decentralisation of care • Seamless communication ICT is vital • Redesign not relocate services in small hospitals • Stakeholder (patient and staff) views important • Move information not patients round the system • Local access to care & diagnostics • Local chronic disease management through clinical networks Changing the shape of the system

20. Changing the organisation inside hospitals

21. Changes in clinical practice + building design Treatment Assessment A&E & Acute Assess-ment Theatres Diagnostics Ambulatory care Follow ups • NHS Direct • Extended GP hours • Minor injuries etc • Specialist GPs • Direct booking • Outreach clinics • Self care Prevention Elective Critical care • intermediate care (avoiding admission) Specialist care Simple surgery Step down / rehabilitation • networks/links to specialist or teaching hospitals • Specialist GPs • Primary care centres • intermediate care (speeding discharge) • at home packages • nursing homes • community hospital beds Stepdown

22. Patient pathway across an organisation Home GP Ambul’ X-ray Labs Ward Sick patient better patient A&E

23. Graduated care process Ambulatory - 23 hr investigations & surgery Outpatients - Generalised - Specialised - One Stop Chest Pain Elderly Assessment Medical Surgical areas Acute Inpatient Care Community + Primary Care Diagnostic Investigation Critical Care Patient Hotel A&E Intermediate Care Facilities • Rehabilitation • Low • Dependency • Respite • Shared Care • Home Care • Social Care Peri Acute Care Primary Care Community Community Primary Care Care pathway

24. Inpatient Aggregations Stroke Acute Medicine & medical COE ENT Maxillo-facial Oncology Haematology Palliative Care Pain Anaesthetics GI Medicine GI Surgery Trauma Cardiology Respiratory Vascular Cardiac Surgery Renal Medicine Renal Surgery Urology Burns Plastic Surgery Breast Services Dermatology Neurology Neurosurgery Liver Medicine Liver Surgery Ophthalmology Metabolic Rheumatology Outpatient Aggregations Oncology & Radiotherapy Haematology Breast Palliative Care Pain Acute Med & medical COE Rheumatology Liver Medicine Liver Surgery GI Renal Urology ENT Maxfac Cardiac Med & Surgery Vascular Respiratory Neurosurgery Neurology Ophthalmology Neurosurgery Neurology Trauma Orthopaedics A&E Dermatology Burns & Plastics Metabolic Unit Objective: to create critical mass across which services can be effectively provided. Flexibility to meet demand. Optimisation through ‘pull’ system Groupings (or aggregation) of patients according to care needs to achieve more homogeneity in terms of disease path, length of stay, skills and service requirements. New groupings away from traditional specialty based classifications. Body mapping for focused patient management. .

25. Small scale organisation (NWLHT) Urgent Treatment Step-down Expert consulting panel Primary Care Urgents Primary Care Chronics Primary Care Follow-up NHS Direct A&E Minors Outpatients Intermediate Care Rehab IP A&E Majors Acute care centre Step-down IP Crit Care Acute IP Recovery & Theatres Elective Care Elective IP DTC

26. Conclusions: changing the shape inside hospitals • Clinical aggregations combining medical + surgical specialties • ICT is vital to be ready at the same time as building • Diagnostic front door • Hot floors • ‘Cellular’ construction round processes • Increased local outpatients + reduced hospital waiting areas • Patient focused care – Do we need Radiology departments? • Staffability: consequences for the workforce

27. So, we need a new planning system…

28. Proposed planning process ( Pre SOC) Workforce Change IT Building changes Communications Stage1 : Health systems with different starting points & drivers New standards & guidelines Building Maintenance Dialogue with Local People Workforce issues Stage 2: Developing the whole system vision Hospital-Community/Primary-Social Stage 3: Defining the limits of the possible Patient and public involvement throughout the process, Stage 4: Options for change Stage 5: Preferred option for whole system Stage 6: Strategies for organisations and functions Stage 7: Outline business case

29. Service planning and environmental design Environmental design getting more detailed>>>>>>>>>>> Estates strategy Outline designs Strategic overview Concept designs Inside/outside hospital care Detailed design Care pathways Detailed design of components New models of care Clinical aggregations Clinical components Service planning scale getting smaller>>>>>>>>> Life of project >>>>>>>>>>>

30. Integrated planning Inside hospitals Changing workforce Whole system configuration New Clinical models Building design procurement Impact of technology Outside hospitals Private public partnerships

31. Possible impact areas Changing workforce Changing roles Patient /staff environment EUWTD E learning Efficient building layout Demography Standard components Redesign of clinical processes New clinical models Building design Knowledge management Access to scarce skills Environmentally robust EPR Intelligent buildings Impact of technology

32. Timescale 29 large PFI projects phase 1 phase 2 Projects 42 LIFT projects New procurement process pilots pilots Next Election?

33. Conclusions

34. Ensure that the £value of good design is recognised More resources to support service planning Decentralisation of care and ICT – but how Patient focused infra-structure what does it mean? Adapt planning processes to new context? Who does what in the new system Can we afford an increased workforce? Future medical equipment needs Key issues for the FHN

35. PFI / LIFT interface What can be done outside hospitals Implications for GMS contract Chronic disease management Affordability Timescales Issues for whole system planning