Transcript Learning from the Experience of Service Centralisation in

Learning from the Experience of
Service Centralisation in Leeds
Dr Greg Reynolds
Consultant Cardiologist
Clinical Director Cardiology and Respiratory
Medicine
First consultant appointment 1996, ST14
College tutor for 4 years (36 SHOs)
Cardiology Training Program Director (31 SpRs) Leeds
and Hull based trainees
On call for Cardiology and for Acute Medicine 1:7
Clinical Director for Cardiology (+Respiratory Medicine)
since 2004
Senior Clinical Leader role (SHA) Darzi
Choose and Book lead (SHA)
Joint chair Cardiology Redesign group (from old Longterm Conditions pathway group) NHS Leeds
Joint chair Public Health steering group NHS Leeds
Reflection: I am quite good at
spending other people’s money
Management style is by agreement
Community Heart Failure project 2003 £500K
PCT expenditure on heart failure service
Cited by Leeds PCT as an example of good
practice
Public Health £500K community service
development 2010 NHS Leeds, website
LeedsLetsChange
Cardiac redesign 2011, NHS Leeds
commissioned blood testing program (BNP)
£120K pa against future savings from the Acute
Trust
Leeds Hospitals
Leeds population 850,000
Two main teaching Hospitals
Leeds General Infirmary (LGI)
older, traditional, central Leeds, close to shops and
restaurants
St James Hospital
built on site of Victorian workhouse,
huge bed base, poorer part of the city
(LGI expensive cars an opportunity)
United Leeds Teaching Hospitals
The two Trusts merged in April 1998
to become the largest single Hospital Trust
in the UK
We all agree we are now one organisation
But of course St James (LGI) is better than
LGI (St James) and always will be
United Leeds Teaching Hospitals
This was a merger of Chief Execs and the
Trust boards in April 1998
In practice the name on the stationery
changed but little direct effect on services
Most services still available on both sites
Became “Leeds Teaching Hospitals”
Reflection on Trust merger
Scottish independence ?
Hostile takeover ?
Slap in the face with a wet fish ?
Jubilee Building
Opened in late1998
New building cost £90 million
Yorkshire Heart Centre built on the LGI site
(+ neurosurgery)
In retrospect built on the wrong site
Cardiology centralisation
A Cardiologist from LGI and a Respiratory
Physician from St James were chatting in
their local pub (Oct 2005)
Wouldn’t it be a good idea if my service
centralised on my site…..
And most people agreed this would be a
good idea
If the idea is right don't let existing cultures
and prejudices dictate strategy
Achieving Clinical
Engagement
Achieving Clinical Engagement
LGI “Yorkshire Heart
Centre”
St James
14 Cardiologists
3 Respiratory
physicians
5 Cardiologists
6 Respiratory
Physicians
74 Cardiology beds
56 Cardiology beds
SJUH Consultants view
But of course St James is better than LGI and
always will be
5 consultants
My predecessor as Clinical Director
Professor of Cardiology
3 very competent clinical cardiologists
This was an entirely competent clinical service
Why change ?
The Trust Board say that patient safety
comes first, but we all know that they only
reward meeting targets which allow (us) to
achieve Foundation Trust status
Was this simply a cost saving exercise ?
SJUH Consultants view
Following a series of meetings 4
consultants accepted the rationale for
change and were in agreement to work to
achieve the goals of the organisation
One did not. A compromise solution was
agreed with the Medical Director. The
consultant has since retired.
Achieving Clinical Engagement
Not everyone will agree, need opinion
leaders on board*
Some solutions need high level external
pressure
(*The recent clinical engagement day I attended said you
need complete agreement on why change is needed….)
Planning service change
Planning service change
130 Cardiology beds cross-site became
100 beds on a single site
Immediate staff concern regarding loss of
employment
Continued to provide clinics and a noninvasive service at St James only
Staff groups
Doctors
Intricacies of reorganising junior doctor rotas.
More SpRs, less FY1s and SHOs
Nurses
Closed one ward on each site with nursing
redeployment very effectively supported by
matrons
Technicians
Agenda for change had recently caused major
disruption, no additional losses
Timetable
First discussed Oct 2005
First meetings Jan 2006
Ward moves Sep 2006
Planning groups, key players including
Ambulance service
Consultant integration was easier to
achieve than nursing integration
Planning service change
Staff have a high degree of loyalty to the
institutions in which they work and do not
welcome change
Once the “tipping point” of accepting the
inevitable was reached it became a
straightforward planning process
We fully committed to the strategy
The year that followed…
The year that followed….
We overprovided on the site that was
losing the service
A cardiologist was timetabled to spend
their full day cross-site (Mon-Fri)
A cardiology SpR was timetabled to spend
their full day cross-site (7 days)
Initially the transferred Cardiology ward
was in a separate block in old
accommodation. This was a disaster
requiring to be changed rapidly
The year that followed
Benefits: £3million immediate annual cost
saving on a budget of £45 million.
Services delivered efficiently with
economies of scale
Consultants able to achieve sub specialist
ambitions
Our average length of stay is 5.5 days
compared to 6.5 days for peers
None of the consultants would go back to
how it was before
Managers see this as a successful merger
My ward sister preferred her previous
ward but only since becoming a female
ward
The year that followed…
Cost savings achieved, quality maintained
and increased efficiency achieved
Other Service Centralisations
Following on from this many further
reorganisations have occurred in Leeds
For 10 years a new Children’s Hospital
was projected.
Leeds has struggled for years to balance
the books
At a cost of £300 million this was deemed
unaffordable
A Children’s Hospital was achieved by
reconfiguring services in existing
accommodation
A major issue for the Children’s Hospital
has been that obstetric services are on a
different site requiring the provision of 2
Paediatric ICUs
Orthopedic services have been split into
elective services on a non-acute site and
acute services in the Jubilee Building
(Yorkshire Heart Centre) with a view to
becoming a designated Trauma Centre
Medicine Centralisation
Leeds has always struggled to achieve
4 hour access targets
The success of Respiratory / Cardiology
centralisation was followed in Medicine
division by centralisation of Acute
Medicine and Elderly Medicine at St
James
Same targets: economies of scale, cost
saving, quality and efficiency
Medicine Centralisation
Medicine centralised in Jan/Feb
Elderly Medicine in December
Complete withdrawal of services from LGI site,
no RMO cover, Failed to look at organisational
need, too focussed on local service need
Continuing bed crises
Some care of elderly services housed in old
remote accommodation with issues about care
standards
Lack of leadership: Insufficient Acute
Medicine physicians to lead the service
Medicine Centralisation
Not able to fully integrate neurology and
acute stroke services on alternative site
Don't have the critical mass to deliver
HASU (hyper acute stroke unit)
(Medicine) Centralisation
Some services (Medicine, Stroke,
Children’s services) have struggled
because of split site services
Personal view:
It would work better if all services were on
one site, if it was affordable I would close
my hospital and move to the workhouse
site
Finally, Regional Cardiology
services and acrimony
Since 2006 the gold standard treatment for heart attack
is an urgent angiogram and coronary stent (PPCI)
This requires a consultant cardiologist and cathlab team
to be available acutely 24 hours a day
Leeds PPCI service covers Leeds, Bradford, York,
Harrogate, Airedale, Wakefield, Dewsbury and
Pontefract
Air ambulance
1000+ cases per year
Population ~ 2.5 million
Leeds has 7 specialist consultants
Regional Cardiology
Agreed that 8 LGI based consultants and 8-12 DGH
based consultants would provide the service
Accommodation suggested that Leeds would pay hotel
costs for DGH consultants, agreed to an on call room
Issue of fitness to work the next day and compensatory
rest payment to the Trust
Total cost for consultant on call reckoned by DGH
participants at £1.2 million pa
Regional Cardiology rota
After a series of meetings we invited the
Leeds Deputy Medical Director with
responsibility for medical workforce issues
to address the group
He was verbally abused and no conclusion
reached
Regional Cardiology rota
We invited the Medical Director of the SHA
to chair the next meeting
General level of tension lessened
After a couple more meetings agreement
was reached with the DGH employing
Trusts with terms and conditions that were
mutually acceptable
Regional Cardiology rota
It is now all sweetness and light
Some solutions need high level external
pressure
It’s not personal
Conclusions
Service centralisation can bring clear benefits
Staff have a high level of loyalty to their
institution
Cross site working is challenging because of the
interdependencies of different services
Senior Medical engagement is absolutely
necessary
Some solutions need high level external
pressure from within or without the organisation
Conclusion
It’s not personal (usually)
Thank you