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Leicester, Leicestershire and Rutland NHS DRAFT v10.0 Our NHS Our Future Next Stage Review - Excellence for All 29 May 2008

LEICESTER, LEICESTERSHIRE & RUTLAND NHS

EXCELLENCE FOR ALL

Ensuring excellence for all by involving and working with the people of Leicester, Leicestershire and Rutland

to improve health and the quality of health services

29 MAY 2008


CONTENTS

EXECUTIVE SUMMARY: ……………………………………………………………………... i

SECTION 1 : INTRODUCTION..................................................................................1

1.1 Purpose of this document..................................................................................1

1.2 Why was the vision developed? ........................................................................1

1.3 The Leicester, Leicestershire and Rutland NHS................................................1

1.4 Structure of the document .................................................................................5

SECTION 2 : OUR NHS OUR FUTURE ....................................................................6

2.1 Local drivers for change....................................................................................6

2.2 National, regional and local service planning...................................................16

SECTION 3 : THE NEXT STAGE REVIEW PROGRAMME.....................................19

3.1 Clinical task groups .........................................................................................19

3.2 The findings of the clinical task groups............................................................20

3.3 Leicester, Leicestershire and Rutland NHS vision ...........................................35

SECTION 4 : WAY FORWARD ...............................................................................39

4.1 Application of the vision and principles............................................................39

4.2 Organisational strategies.................................................................................48

4.3 Some immediate changes...............................................................................49

4.4 Regional services............................................................................................50

4.5 Forward planning ............................................................................................53

4.6 Engagement and consultation .........................................................................53

4.7 Working with partners......................................................................................55

4.8 Ongoing local accountability............................................................................55

4.9 Equality impact assessment............................................................................55

SECTION 5 : CONCLUSION ...................................................................................57


Appendices

Appendix 1 Clinical Task Group Summary Reports

Appendix 2 Cross Cutting Themes

List of Figures

Figure 1 : LLR current hospital configuration........................................................4

Figure 2 : Life expectancy estimates by PCT .......................................................7

Figure 3 : Key health indicators - Leicester City ...................................................7

Figure 4 : Key health indicators - Leicestershire County .....................................8

Figure 5 : Key health indicators - Rutland County ................................................8

Figure 6 : LLR Our NHS Our Future Next Stage Review Clinical Task Groups ..19

Figure 7 : Maternity and newborn care CTG priorities ........................................21

Figure 8 : Whole systems model for children’s and young people’s care............22

Figure 9 : Overarching population model for integrated children and young people’s services in LLR ....................................................................23

Figure 10 : Staying healthy priority areas .............................................................26

Figure 11 : Charter for mental health in Leicester, Leicestershire and Rutland.....27

Figure 12 : Specialist hyperacute stroke unit proposal .........................................31

Figure 13 : The Leicester, Leicestershire and Rutland NHS vision.......................36

Figure 14 : New stroke pathway for better outcomes ...........................................40

Figure 15 : Future model of care – maternity and newborn services ....................44

Figure 16 : Chest Pain / Angioplasty Model of Care.............................................51

Figure 17 : How this will improve care for…a woman with chest pain ..................51

Figure 18 : Proposed model of care – major trauma ............................................52

Figure 19 : Maternity and newborn care CTG proposals ......................................59

Figure 20 : Children’s Services CTG proposals....................................................61

Figure 21 : Staying Healthy CTG proposals .........................................................63

Figure 22 : Mental Health and Learning Disabilities CTG proposals.....................66

Figure 23 : Acute Care CTG proposals ................................................................68

Figure 24 : Planned Care CTG proposals ............................................................71

Figure 25 : LTC CTG proposals ...........................................................................73

Figure 26 : End of Life Care CTG proposals .......................................................75

Figure 27 : Overview - cross cutting themes ........................................................78

Figure 28 : Dahlgren and Whitehead (1991) – The main determinants of health..87

List of Tables

Table 1 : Key characteristics of the LLR population ............................................2

Table 2 : LLR NHS health service principles .....................................................37

Table 3 : Proposed planned care pathway – rectal bleeding .............................46

Table 4 : Children’s services – improved use of resources ...............................47

Table 5 : Implementing the National Interim Report ..........................................49

Table 6 : LLR Health economy – financial summary 2005/06 to 2007/08..........86


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EXECUTIVE SUMMARY

1 Purpose of this document

This document has been developed as part of the Leicester, Leicestershire and Rutland (LLR) NHS Our NHS Our Future Next Stage Review programme. It presents an overarching ten year vision for health and health services together with some key principles for service development. The vision addresses two key issues:

Improving the health and well being of the people of LLR and reducing health inequalities.

Redesigning and reconfiguring health service to improve quality and outcomes and ensure best value for patients.

This vision applies to all commissioners and providers of NHS services within LLR.

2 Leicester, Leicestershire and Rutland NHS Vision

Based on work undertaken by local clinical task groups, a local NHS ten year vision for adults and children and for physical and mental health services has been developed:

Ensuring excellence for all by involving and working with the people of Leicester, Leicestershire and Rutland to improve health and the quality of health services.

The key themes of this vision are that:

Patients, the public and communities will be fully involved in improving their health and the quality of local health services.

Health services will be fair, effective, personalised and safe.

Across Leicester, Leicestershire and Rutland people will be supported to make healthy choices, stay healthy and self-care.

Services will need to become increasingly integrated across primary care and secondary care and with local authorities.

Services will be provided locally where possible and centralised where necessary – there will be more care available closer to home. At the same time more specialist care will be provided in high quality, specialist centres of excellence for those services where centralisation improves outcomes.

People will be able to access the right services – when they need them.

These themes are drawn together in the diagram below.


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Fair Personalised

Effective Safe

Wide range of community based/

local health services

Effective high quality acute and specialist care

Support to make healthy choices and self-care

Accessible and high qualityprimary care services

3 LLR NHS service development principles

The work of the clinical task groups and the themes of the proposed vision have been translated into seven principles which the whole LLR health economy have agreed to work to. These are to:

Ensure excellent clinical outcomes for patients.

Put patients and the public at the heart of service delivery and involve them in its planning.

Enable patients where possible to take responsibility for their own health and well-being and the treatment they receive.

Focus on reducing health inequalities.

Offer a real choice of easily accessible services.

Make best use of resources.

Impact on the wider determinants of health and well being.

These principles have been derived from the Next Stage Review programme work and run throughout the programme’s service change proposals and strategic planning work.


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4 How the vision and principles were developed

The LLR NHS vision and principles have been developed through the LLR Our NHS Our Future Next Stage Review programme. At its heart is the work of eight multi-disciplinary teams drawn from all LLR NHS organisations and health and social care partners. The eight clinical task groups (CTG) recommendations span all aspects of health care and health services, from birth through to end of life:

NHS partners, clinicians and staff have been absolutely central to the Next Stage Review process. There has been high level clinician involvement in this process from each sector of the health. Equally, public and patient involvement has been integral. Over 300 members of the public have taken part in discussion events focussed on the work of the eight CTGs. Many others have been engaged through contact with representative groups, clinical networks, Patient and Public Involvement Forums (PPIFs), programme boards and through Our NHS Our Future open events. Further engagement will be taken forward throughout the summer.

5 Conclusion

While current services across LLR go some way to meeting local needs, there are number of reasons why services now need to change. We believe the people of LLR deserve the best. At the heart of the LLR vision is the desire to improve the quality of people’s lives, prevent ill health, reduce health inequalities and deliver services in settings that are more convenient to the people that use them. It will change the nature of care provided in a range of settings: in primary care and community facilities; in ambulances; in patients’ homes; and in acute hospitals. These changes will need to be delivered as a coherent, integrated plan. The vision will only be realised by everyone working together to develop ideas and options for change and implement agreed service changes. Engaging and consulting widely on the proposed vision and options to realise the vision will form the next steps on the journey towards Excellence for All.


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SECTION 1 : INTRODUCTION

1.1 Purpose of this document

This document is the collective work of the NHS organisations within Leicester, Leicestershire and Rutland (LLR). Its purpose is to help to draw together the basis to a local ten year vision for health and health services. Its intended audience is, primarily, local NHS organisations and their partners in local government and the voluntary sector. A summary of the document has been prepared for patients and the public.

The LLR NHS vision has been developed as part of a local Our NHS Our Future Next Stage Review programme. Though the programme is local, it is linked to national and regional programmes. It therefore draws on national policy, as well as best clinical evidence, existing local strategic plans and the recommendations of many local health care professionals. It is quality driven, not financially driven.

The document will be used to underpin the development of commissioning strategies for Leicester City Primary Care Trust and Leicestershire County and Rutland Primary Care Trust as well as the service development strategies of the University Hospitals of Leicester NHS Trust and the Leicestershire Partnership NHS Trust as they proceed with applications for NHS Foundation Trust status. It should also inform the development of other providers’ strategies in the area, for example local authority partners, East Midlands Ambulance Service and private providers.

1.2 Why was the vision developed?

The local Our NHS Our Future Next Stage Review programme was launched to address two key issues:

The health of the LLR population as a whole, while improving, could be better. With healthier lifestyles, people could live longer and better. There are also great inequalities in health between different groups within the local population. The local NHS can do more to make everyone healthier and to reduce health inequalities.

Health care can also be improved. While there are many examples of good practice and high quality care, there are also services that are not yet able to work to best practice, which reduces their effectiveness. The local NHS can redesign and reconfigure services to improve quality and outcomes.

1.3 The Leicester, Leicestershire and Rutland NHS

1.3.1 Population served

The LLR NHS serves a population of nearly one million people (927,1001) distributed across nearly 1,000 square miles. Two Primary Care Trusts (PCTs) commission health

1 As at 2004 estimates (GP Relevant Population Estimates 2004, Compendium of Clinical

Indicators © Crown Copyright), Leicestershire County and Rutland PCT serves a population of c625,100 and Leicester City PCT a population of c302,000.


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services on behalf of this population: Leicester City NHS Primary Care Trust and Leicestershire County and Rutland NHS Primary Care Trust. Over half the population lives in central Leicestershire and looks to the city for many health services.

The LLR population has diverse characteristics and health needs. Key characteristics are summarised in the following table.

Table 1 : Key characteristics of the LLR population

Leicestershire and Rutland populations Leicester City population

Age Older than the national age profile - 42% aged 45 and over compared with 40% nationally.

Below national average number of people aged 25-44 years.

Number of people within the 75 – 84 year age bracket expected to increase by 16% over the next 10 years.

Young age profile - 37% of the population aged 0-24 (31% nationally).

33% aged 45 and over (40% nationally).

Deprivation Generally low levels of material deprivation - less than 2% of the population live in areas defined as the “most deprived 20%” of the population nationally

38% of the population live in ‘wealthy’ areas regarded as “the 20% most affluent” nationally.

Number of small market towns classified as “prospering smaller towns”

2.

Pockets of disadvantage in areas close to Leicester, around market towns and in ex-coal mining areas.

‘Spearhead Area’ by virtue of the levels of material deprivation and poor health outcomes experienced by the population.

Nearly 70% of the population of Leicester city live in the 20% of areas that are defined as the most deprived nationally.

Less than 6% of the population experience better than average levels of material deprivation.

Ethnicity Nearly 95% of the population are from white ethnic groups.

Main minority ethnic group is South Asian, particularly in Loughborough and Oadby and Wigston. (3.5% of population).

36% of the population are from minority ethnic groups (compared with 9% nationally).

Almost a third (29.9%) of the population is South Asian.

In the near future the population profile will be such that there will be no single majority ethnic background in the city.

Particular health needs of the population are discussed further in section 3.

2 In terms of Office for National Statistics (ONS) cluster areas. ONS cluster areas group together

geographic areas according to key characteristics common to the population in that grouping.


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1.3.2 Leicester, Leicestershire and Rutland health services

The LLR NHS provides a wide range of primary, community, acute and specialist health services to the Leicester, Leicestershire and Rutland population. These services are briefly described below. The vision for local health services applies equally to them all.

Primary care services

Primary care services are often the first point of contact for people requiring health care. Primary care services include GP services, dentistry, optometry and pharmacy. For most patients their local primary care providers are their most frequent point of contact with health services and 90% of care is delivered here.

Across the areas covered by Leicestershire County and Rutland PCT there are around 340 GPs working in 84 GP practices covering a mix of rural and urban areas, serving approximately 660,000 registered patients. Some locally enhanced services are in place to support delivery of key services outside of the core GP contract but which are local priorities for extending the range of primary care services on offer to patients. These include, for example, minor injuries services and anti-coagulation clinics.

Within the boundaries of Leicester City PCT, primary medical services are delivered by around 200 GPs working in 63 practices. They serve a resident population of around 290,0003.

NHS Direct provides information and advice about health, illness and health services, to enable patients to make decisions about their health care. Services are provided through telephone health information, a health website and a digital TV service.

Community services

Community health services are those NHS services provided outside of the main hospitals, in settings such as small community hospitals, clinics and patients’ homes. Community services are provided in a widely dispersed network and provide support to patients with long term conditions and other particular needs. Services include district nurses, allied health professionals, health visitors and community psychiatric nurses.

Within Leicestershire and Rutland there are a number of community hospitals, located in the main market towns on the periphery of the county borders (as illustrated with green crosses in the map below). There are currently no community hospital facilities within the City of Leicester boundaries or the greater Leicester area adjoining the City.

3 This figure is the GP registered population and therefore differs from the city’s resident

population.


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Figure 1 : LLR current hospital configuration

Note – Leicester Partnership NHS Trust provides services across the whole of LLR.

Acute and specialist services

Acute and specialist services are predominantly provided from the three hospital sites4 that make up the University Hospitals of Leicester NHS Trust (UHL). Across the health economy as a whole 84% of non-elective activity and 81% of elective (inpatient and daycase) activity is commissioned from UHL5. The remainder is commissioned from community hospitals and providers outside of LLR – as shown in the map.

Acute hospitals provide services to:

Patients who are too ill to be cared for at home or in other community settings.

Patients who need particularly specialist equipment or skills, which can only be provided in a limited number of places.

4 The Leicester Royal Infirmary, Glenfield Hospital and Leicester General Hospital.

5 Data source Dr Foster.

NHS


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Mental health and learning disability services

Mental health and learning disability services are mainly provided by Leicestershire Partnership NHS Trust (LPT). The Trust provides a range of services in a number of inpatient and community based settings, including child and adolescent mental health; adult mental health; mental health services for older people; specialist mental health; substance abuse services; eating disorders; common mental health problems and learning disability services.

Patient transport services

Local NHS patient transport services are provided by the East Midlands Ambulance Service (EMAS). EMAS provides unscheduled care (such as emergency treatment) and patient transport across Derbyshire, Nottinghamshire, Lincolnshire and Northamptonshire as well as LLR.

1.3.3 Financial position

In 2006/07 the four NHS organisations within LLR collectively made a £4.11 million surplus and expect to make a £3.94 million surplus in 2007/08. All NHS organisations within LLR are in financial balance and have created small surpluses that will enable future investment.

The vision and related changes to services discussed in this document are therefore not driven by a need to ‘save’ money but rather to ensure high quality and best value for patients. A good financial position helps makes service improvements possible.

1.4 Structure of the document

The remainder of the document is structured as follows:

Section 2 describes the reasons (“drivers for change”) for undertaking service redesign and describes the vehicle used to co-ordinate the planning of changes - the Our NHS Our Future programme.

Section 3 summarises the work of local clinical task groups and sets out an overarching vision for health care, together with key principles for service development.

Section 4 discusses some ways in which the principles can be met through service change proposals, and some related strategic planning work is described. The means by which the Next Stage Review will be taken forward are then discussed, including some immediate service improvements locally and regionally, forward planning, continued patient engagement and partnership working. Equality impact is discussed.

Section 5 sets out some conclusions.


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SECTION 2 : OUR NHS OUR FUTURE

This section of the document describes the reasons (“drivers for change”) for undertaking service redesign and describes the vehicle used to co-ordinate the planning of changes - the Our NHS Our Future programme.

2.1 Local drivers for change

Much has been achieved to improve the health of the people of Leicester, Leicestershire and Rutland. The population’s overall life expectancy is at an all time high and continues to improve. There are some excellent services and the health economy has successfully recovered from past financial problems. However, there is much remaining to do. In spite of achievements to date, “no change” is not an option. Reasons for this are expanded on below.

2.1.1 Improving the health of the people in Leicester, Leicestershire and Rutland and reducing health inequalities

Whilst some people within LLR live healthy lives for longer, this is not the case for everyone. Currently, the urban and rural populations experience different health outcomes and differences in life expectancy. Those who are less healthy tend to be on lower incomes, live in deprived areas and/or belong to groups that are vulnerable to particular health problems. They are not enjoying improvements in their health, or life expectancy, at the same rate as their neighbours. For example, the East Midlands Ambulance Service responds to the most deprived areas in LLR four times more often than in areas in the least deprived areas. The fact that ambulances are called to certain communities more than others indicates differing levels of health need and different behaviours in accessing services.

Local life expectancy and health indicator profiles are summarised below.


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Figure 2 : Life expectancy estimates by PCT

Life Expectancy Estimates 1991-1993 - 2003-2005

66

68

70

72

74

76

78

80

82

84

1991-1

993

1992-1

994

1993-1

995

1994-1

996

1995-1

997

1996-1

998

1997-1

999

1998-2

000

1999-2

001

2000-2

002

2001-2

003

2002-2

004

2003-2

005

England Male

England Female

Leicestershire County and Rutland PCT(Average) Male

Leicestershire County and Rutland PCT(Average) Female

Leicester City PCT Male

Leicester City PCT Female

Health inequalities are further described in the figures below6.

Figure 3 : Key health indicators - Leicester City

Overall, the indicators of health for people living in Leicester City are worse than the England and the East Midlands average. On average people live shorter lives in Leicester City than in England as a whole.

Teenage pregnancy rates are high compared to the England average.

Lifestyle indicators are generally worse than average:

– It is estimated that almost 1 in 3 adults smoke.

– 1 in 4 people are obese.

– Only 1 in 4 people eat healthily.

– It is estimated that 1 in 7 binge drink (lower than average).

The death rate from smoking and early death rates from heart disease and stroke are higher than average.

The percentage of people with recorded diabetes is higher than average with diabetes affecting 1 in 18 people in Leicester.

The infant mortality rate is 4 times as great in east Leicester as in west Leicester.

The perinatal mortality rate is 2 times as great in east Leicester as in west Leicester.

The still birth rate is nearly twice as great in east Leicester as in west Leicester.

6 Sourced from Association of Public Health Observatories (APHO), Department of Health and

Leicester City Local Area Agreement.


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Figure 4 : Key health indicators - Leicestershire County7

Overall, the indicators of health for people living in Leicestershire are better than average when compared to England and the East Midlands. On average, people live longer lives in Leicestershire than in England as a whole.

Teenage pregnancy rates are low compared to the England average.

Lifestyle indicators are generally better than average with some areas of concern:

– Levels of physical activity are higher than average.

– Nearly 1 in 4 adults are obese.

– Only 1 in 5 adults eat healthily.

– It is estimated that more than 1 in 5 adults binge drink (higher than average).

The death rate from smoking and early death rates from cancer, heart disease and stroke are below average but the rate of improvement for early deaths is less than for England as a whole.

Although the percentage of people with recorded diabetes is lower than average, diabetes still affects 1 in every 29 people in Leicestershire.

Figure 5 : Key health indicators - Rutland County8

Overall, the indicators of health for people living in Rutland are better than average when compared to England and the East Midlands. On average people in Rutland live longer than in England as a whole.

Teenage pregnancy rates are low compared to the England average.

Lifestyle indicators are generally better than average:

– It is estimated that more than 1 in 6 adults smoke.

– Less than 1 in 3 eat healthily.

– It is estimated 1 in 7 binge drink (lower than average).

– Levels of physical activity in adults are above average.

The death rate from smoking and early death rates from cancer, heart disease and stroke are below average.

The diverse nature of the urban and rural populations result in each having particular health needs. We need to address this by developing services tailored to local populations and targeting such services appropriately.

There are a variety of specific actions and targets for addressing health inequalities, contained in the local joint strategic needs assessment and in local area agreements. These are separately documented9.





9 Joint Strategic Health Needs Assessment.


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2.1.2 Responding to increasing public expectations

Though NHS services have improved, improvements have not necessarily kept pace with rising expectations. There is particular concern over hospital cleanliness, continuity of care, being able to access health services when they are needed (particularly in primary care) and improved patient transport. For example, UHL’s overall Healthcare Commission ratings for 2006/07 are ‘excellent’. However, the Healthcare Commission’s 2007 Inpatient Survey identifies patient satisfaction with inpatient care is in the intermediate 60% of trusts nationally. There are no indicators where UHL performance is above the national average or in the best 20% performing trusts. To become excellent our services will need to move consistently into the top 20%. Similarly, we know patients want us to do more to improve access to primary care services, particularly in the city of Leicester where the National GP Survey of Patient Access and Choice, Your Doctor, Your Experience, Your Say 2006/07 revealed satisfaction levels with GP services in Leicester City were the lowest in the East Midlands in relation to accessing a GP within 24 hours and making advance bookings. Satisfaction was also lower than national and East Midlands’ levels with telephone access, booking to see a particular GP and opening hours. Across Leicestershire County and Rutland PCT the quality of general practice in the same survey was generally found to be good. At PCT level, Leicestershire County and Rutland PCT performed favourably in comparison with other East Midlands PCTs and national benchmarks.

In the future, the local NHS will have to work differently to meet rising expectations and respond to the population’s concerns. (As part of the local Next Stage Review, discussion events have been held with members of the public. Some of the reactions to proposed changes in NHS services are discussed in section 3 of this document.)

2.1.3 Basing care on best evidence and research

The NHS needs to act more quickly when new evidence shows that outcomes for patients can be achieved by changing the way care is delivered and that such changes in care will be cost effective. As one example, some recommendations of the Royal College of Physicians National Sentinel Stroke Audit (2006) and the National Clinical Guidelines (2002) are still to be implemented across LLR. Across England 840 strokes each year would be prevented and 3,900 stroke victims each year would regain their independence10 if four specific improvements were put in place: increasing stroke unit capacity; rapid access to transient ischemic attack (TIA) services; rapid scanning to enable thrombolysis; and early supported discharge arrangements11.

Truly excellent health services come from aligning excellence in clinical practice with excellence in teaching and research. Patient experience and outcomes are enhanced significantly from working this way. The University of Leicester Medical School, in partnership with the NHS, has a substantial track record of aligning such research and service excellence in every stage of the National Institute for Health Research (NIHR) innovation research pathway. Close working relationships between academic and NHS

10 Who would otherwise have died or experienced long-term dependency.

11 Mending Hearts and Brains: Clinical Case for Change, Professor Roger Boyle, 2006.


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staff have brought these benefits to the patient's bedside. We believe that it is essential that we maintain and develop further our contribution to the realisation of the NIHR vision. This will not only impact on national and international healthcare but also on the quality of service that we deliver to patients throughout LLR. It is well recognised that research active organisations attract dedicated, innovative staff and that patient experience and outcomes are enhanced significantly in these organisations. Furthermore, a research culture is also essential for the development of world-class, evidenced-based commissioning.

The Next Stage Review offers many opportunities for patient centred research. The local NHS is committed to building on existing collaborations over the next ten years. It is, and will remain, a priority to ensure the NHS benefits from strong “bench to bedside” (translational) research that improves patient care. Already, as one example, UHL cardiac services are recognised nationally and internationally as being at the leading edge of clinical practice and high quality patient care. This is a powerful demonstration of the benefits of a strong alliance between academic and NHS endeavour and one that we want to work to replicate in further areas of clinical and academic expertise. In taking this forward the local NHS will use every opportunity to secure biomedical research units in areas of established academic and NHS strengths12 as part of a coherent plan to develop nationally and internationally recognised translational research and, through this, further excellence in patient care.

Our reputation and potential for cross-sector, applied health care research has been recognised recently by the award of approximately £10 million over five years to establish a NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC). This is matched by combined funding of £2 million per annum from all acute, tertiary, mental health and primary care trusts in LLR, academic partners, the Deanery and health care industry. The LLR CLAHRC will design and deliver:

Applied research - i.e. original investigations undertaken to acquire new knowledge directed towards a specific practical aim or objective.

Implementation of research evidence - i.e. evaluation of novel initiatives to encourage adoption of evidence-based practice or clinical effectiveness.

The CLAHRC’s themes of prevention, early detection, education, self-management and rehabilitation will target chronic disease and public health interventions where there is potential gain for patients within 3-5 years.

National changes to the R&D agenda rightly require a direct correlation between investment in research and substantive research output. The alignment of clinical services strategies and the University of Leicester's research strategies will ensure a sustainable, discerning, and ultimately effective programme to accelerate the rate of improvement in patient care. This brings great opportunities to benefit our patients.

The local NHS, in partnership with the University of Leicester, recognises the important

12 These typically provide four years capital and revenue funding and potentially provide the

platform for a subsequent bid to become a biomedical research centre.


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changes taking place on the national R&D landscape and embraces the research strategy of the NIHR and recognises its local and national benefits. Fundamental changes in clinical services offer both opportunities and challenges to our ability to perform research. We will respond to the challenges and take full advantage of the opportunities to ensure that our patients are served by world-class research and researchers. We will seek out opportunities to create exceptionally fertile research environments in which to translate these national changes into local benefits for patients. Strategic planning work includes aligning the strategic priorities of the NHS with the University of Leicester and exploring potential collaborative opportunities with adjacent University providers including Loughborough and Nottingham. An increasing volume of teaching and research is being undertaken in the community and the local NHS is committed to educating health care professionals so that they are best equipped to care for patients increasingly in a community setting supported by intelligent and imaginative use of technology.

2.1.4 Taking forward local clinicians’ and NHS professionals’ recommendations

Clinicians and other NHS professionals want to see their patients receive seamless care that transcends organisational boundaries. They find this difficult to achieve in practice. For example, important patient information may be unavailable to clinicians in one organisation because it is recorded and stored in a different organisation.

As part of our overarching ambition to ensure world class services for local people, local clinicians’ have identified a need to improve communication systems, to move away from ‘paper-based’ records, and to make it easier to transfer clinical information safely and quickly between clinicians and organisations. They have also expressed a clear desire for increased partnership and multi-agency working as an important mechanism for taking services forward.

The local NHS needs to support development of clinical leaders to make these changes. Importantly, taking forward local clinicians’ and NHS professionals’ recommendations will mean developing an LLR-wide workforce, education, and training strategy that aligns recruitment and training with changing needs.

2.1.5 Delivering more care locally

Across the UK, the direction of travel for health services is to ensure that people with less complex conditions are cared for within services that are as close to their homes as possible, where safe and cost-effective to do so.13

The nature of community care and what can be provided in the community is changing. Many more services can now be provided in the community with the development of, for example, 24/7 community nursing and advances in services and technology. In particular, developments in medicine and clinical practice mean that, in many cases, health care no longer always has to mean care in specialist acute facilities such as the Leicester Royal Infirmary, Leicester General or Glenfield Hospitals. Some procedures that used to involve long stays in hospital in the past can now be done without the need

13 White Paper, Our Health, Our Care, Our Say, 2006.


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for an overnight stay. Many patients can now be swiftly discharged and get the rehabilitation care they need at home or in the community. Similarly, some procedures which have previously needed a trip to hospital can now take place in a GP surgery. The work of the Next Stage Review has identified that, for example, more patients could be treated for certain causes of rectal bleeding in a GP’s surgery and avoid the need to attend an acute hospital unless absolutely necessary. As another example, removing a patient’s gallbladder used to be done through a large cut on the abdomen which needed several days to heal. Now this can be done through “keyhole” surgery often in a single day, allowing the patient to return home and to full activity much more quickly.

As technology improves we are doing more and more ‘minimally invasive’ surgery in increasingly complex areas – surgery without big ‘open’ surgical procedures. For example (and as a result of cutting edge and internationally renowned research and development programmes) we can now repair heart valves in increasingly elderly and frail patients via the smallest of incisions made in an artery in the leg without the need for a general anaesthetic. The patient can typically go home after a day or so.

Many people, such as those with long term and / or complex conditions like heart failure and diabetes, who would previously have frequently been readmitted to hospital when their condition worsened, can now get the care they need in their own home or in a local clinic instead of being admitted to a hospital bed. Currently however:

When Leicester City PCT’s use of acute hospitals is compared to that nationally, the PCT is ranked 138/152 (i.e. significantly worse than average) in terms of effective use of emergency hospital care. The PCT has 43% more emergency admissions than would be expected for the demographic and health needs profile of the city.

We have identified the current lack of community hospital provision in Leicester City and its surrounding boundary areas earlier in this document. Only 1% of Leicester City PCT’s acute outpatient activity currently takes place within a primary care setting, meaning the overwhelming majority have to travel to acute hospitals where parking is often problematic.

By contrast, within Leicester County and Rutland PCT’s boundaries 16% of acute outpatient activity is locally provided through community hospitals. This is already planned to increase, to be more responsive to local needs.

To provide care closer to home we need to increase the range of improvements and investments in primary care and community services. For example:

Based on guidelines issued by the British Medical Association and the Royal College of General Practitioners, the health economy as a whole has a shortfall of 40 GPs. There is a clear need for this to change so that we build the capacity to deliver as full a range of services as locally as possible.

Currently the City of Leicester is supported by a large number of small, often single handed GP practices. This can restrict the hours they can open. In addition many GPs work from premises that are no longer fit for purpose. Many city GPs are approaching retirement, so a plan is needed to replace them. There is also a need to increase overall access to GP services in the City of Leicester.


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Community hospital facilities have been developed within smaller towns but not in the City of Leicester. For Leicester residents (and those in the communities immediately adjoining the city) the kind of care that could be provided locally has historically been provided in the acute hospitals. Patients are therefore either staying longer in acute and specialist hospital beds than they need to or being accommodated in one of the health economy’s county based community hospital beds a considerable distance from their home.

There will also be a need to refocus the nature of the community hospitals in Leicestershire and Rutland to make best use of them. For example, they could provide for:

– More support for patients to stay in their homes as long as possible, through larger community nursing teams working with consultant geriatricians, GPs, adult social care and the voluntary sector.

– An extended range and availability of services in five ‘one-stop hubs’.

– Two walk-in centres, one for north Leicestershire, one for south Leicestershire.

– Care for minor injuries and illnesses to be offered through a range of options, which would include GP surgeries, pharmacies, community hospitals, Walk-In Centres and the out-of-hours telephone service

– More diagnostic tests, more outpatient clinics, and more day case surgery in community hospitals.

– Extended palliative care and rehabilitation services.

The local NHS now has the opportunity to use community nursing teams and the “24/7” mobile health expertise within EMAS to support many more people in their own homes in non-emergency situations. Rather than take patients to hospital for certain outpatient appointments, services could be brought closer to home or into patients’ homes.

2.1.6 Providing higher quality, more specialised care

At the same time as some services can safely be distributed into local facilities there is a real need for the NHS to increasingly concentrate a number of specialist services into single locations in order to ensure a critical mass of specialist staff and equipment and sufficient activity to ensure clinical skills stay up to date and develop in line with modern best practice. The most seriously ill, such as people suffering from a stroke, cancer or a heart attack, need more specialised care.

Across the NHS there is a recognised need to ensure large emergency hospitals are well supported to care for people with an acute clinical need. To ensure sufficient volumes of work to maintain specialist staff expertise, support high-tech equipment and technologies and allow sufficient consultant presence some highly specialist services will need to be concentrated in specialised departments within appropriate acute hospital facilities.


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2.1.7 Using NHS workforce effectively

Across the NHS, staff are the most valuable resource and locally the NHS must make sure their abilities are fully used. Service change must help ensure the effective use of staff for example:

We need to make the best possible use of scarce skills by bring these staff together in one place where they can keep their skills up to date and continue to develop.

Technology and medical advances are making it more and more possible to care for people in local communities and their own homes. We need to support our staff to provide excellent care across clinical networks.

We want to make best use of the diversity and talent of NHS staff. This means supporting life long learning and making sure staff are valued and rewarded fairly. This is an important part of Improving Working Lives of NHS staff.

In addition to this, we must ensure we attract, support, develop and retain the full range of staff needed, from unqualified support workers to highly trained specialists. To support this we will ensure that we work together as a health community and in partnership with education organisations and with our staff and their representatives to:

Identify and deliver the changes needed in workforce, their skills, roles, training and development and to ensure the most effective and flexible use of appropriate staffing to meet the changing demands of different care models.

Ensure that our staff experience high levels of job satisfaction, stimulating and safe working environments, support and development and a good quality of work life balance

In doing so we will enhance the reputation of the local health organisations as places to work, where the needs of the patient are paramount, and staff are supported to deliver the best care.

2.1.8 Improving the condition of NHS estate across the health economy

The physical condition of the local NHS estate needs to improve if we are to deliver first class health care for the population. There is a need for investment in GP premises, community facilities and acute hospital premises. For example:

Acute and specialist services are currently provided from a varied mix of buildings, some dating from 1771. An ambitious project to either replace or refurbish the entire UHL estate through a Private Finance Initiative (PFI) had been planned. This project had meant that many smaller but important investments were deferred. Following the cancellation of the PFI scheme in 2007, deferred investment has left many challenges now needing to be resolved to ensure acute and specialist services are provided from modern and fit for purpose facilities.

Specialist mental health and learning disabilities are currently provided from a


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variety of properties that range from Victorian to modern day design. There are new facilities, for example a new learning disability assessment and treatment unit and adult low secure facility will both open this year. However many facilities are not fit for future models of care or are not necessarily in the right locations.

Within Leicestershire and Rutland Counties, community health services are provided from premises ranging from small team bases to large community hospitals. All vary in age and condition:

– Inpatient wards do not meet the suggested standards expected for the future – for example, there is a lack of single rooms.

– The layout in each community hospital could be improved to comply with standards and improve the way services could be used in the future.

– Office accommodation is sometimes in clinical areas, which is not a good use of scarce clinical space.

– There is limited scope for development on certain sites.

– There is poor use of land.

– Significant investment is needed to upgrade sites to 21st century standard.

Leicester city community services are currently provided from a small portfolio of properties including health centres and GP practices. Historically the standard of this accommodation has been poor and facilities are not universally fit for the delivery of modern health services. To address this situation, Leicester City PCT became a ‘LIFT’ area in 2004 and working in conjunction with a private sector partner, has developed four new health centres in Leicester city. A further centre is due to open in early 2009. These health centres have been developed with built in flexibility to adapt to changes in service models. However, much of the remaining estate either needs replacing or major refurbishment work14.

Leicester City PCT is currently undertaking a review of all premises and will be putting in place a process to encourage GPs to improve their premises and thus provide a better experience for patients. For example, as discussed earlier, it is likely that community facilities, including some form of intermediate and rehabilitation unit will be required.

2.1.9 Responding to the future demands on health services

NHS services must meet not only today’s challenges but also the challenges of tomorrow. The population of Leicestershire and Rutland County PCT is expected to increase by 3.7% by 2012. As Leicestershire has been designated a growth area it is anticipated that there will be an inflow of approximately 70,000 people into the area over

14 Plans for replacements are being drawn up as part of the review of the PCT’s Strategic Service

Development Plan for LIFT which will be finalised once the city’s Primary and Community Services Plan is complete later in the year.


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the next 14 years. The population of Leicester City PCT is set to rise by 1.1% over the same time frame15.

Demographic changes are also likely to have far-reaching implications including:

Rural areas within the health economy seeing increasing numbers of older people who will need access to care as close to their homes as possible. In the county of Leicestershire there is a higher proportion of older adults and the elderly, with 36% of the Leicestershire population aged over 50, compared with the England average of 34%. In Rutland older adults and the elderly account for 37.6% of the population. The proportion of elderly people will continue to rise between now and 2020 with associated consequences for health and transport.

The rising incidence of chronic, long-term conditions such as coronary heart disease (CHD), hypertension, and chronic obstructive pulmonary disease (COPD) and other illnesses as people with ill health live longer. It is anticipated that by 2014 the number of people living with COPD, Stroke, and CHD will rise by about 17%. There will also be a rise of 12% in hypertension and a rise of 21% in dementia. These patients will need local, high quality services that keep them out of acute hospital settings and maintain independence at home as long as possible16.

Urban city areas will experience an increase in younger and ethnic populations with specific health needs including reproductive medicine and diabetes care for which the LLR NHS will need to ensure it has the service capacity to respond.

Service design and capacity plans must take into account such changes.

2.2 National, regional and local service planning

2.2.1 National programme

The NHS is changing. Since the publication of The NHS Plan (2000) a framework for the nation’s future health care system has been developed through a range of policy documents17. The intent has been that the NHS of the 21st century should be clinically driven, patient centred, and responsive to local communities. It should offer choice, and

15 ONS population projections 2006 – 2012 (2004).

16 Leicestershire Joint Strategic Needs Assessment 2007/08- Leicestershire County Council and Leicestershire County and Rutland PCT (April 2008).

Rutland Joint Strategic Needs Assessment 2007/08 - Rutland County Council and Leicestershire County and Rutland PCT (April 2008).

17 These include the Wanless Reports; Tackling Health Inequalities: A Programme for Action;

Taking Healthcare to Patients: Transforming NHS Ambulance Services; Choosing Health; Our Health, Our Care, Our Say; Shifting Care Closer to Home Demonstration Sites; Health Reforms in England; A Stronger Local Voice; Social Cohesion Strategy; Health Challenge for England; Commissioning a Patient Led NHS; and World Class Commissioning.


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deliver services in settings that are more convenient to the people that use them. It should prevent ill health, save lives, and improve the quality of people’s lives. These messages all reinforce the local drivers for changes discussed above.

In 2007 the NHS in England began a Next Stage Review, led by Lord Darzi. The review was given the name Our NHS Our Future, and was designed to build on several years of service change and growth, organisational change and investment since the publication of the NHS Plan in 2000. The review was designed to look forward over the coming years, to make plans for meeting rising public and patient aspirations for health and health care; and in doing so:

Engage NHS clinicians and staff in the process.

Improve the way services are delivered, so that they are fair and equitable; personalised; effective; safe; and locally accountable.

Establish a vision for the future of the NHS.

The national programme is reflected at regional level across England, with each strategic health authority (SHA) leading Our NHS Our Future activities. The NHS East Midlands programme is discussed below.

2.2.2 Regional programme

The NHS East Midlands published its strategic plan in October 2007. Better Health, Better Care: Preparing for the Next Stage made six promises to the East Midlands public. These are:

A positive experience for all our patients, where everyone is treated with courtesy and respect and personal dignity is a priority. A service which offers real choices where patients and their carers have influence and are involved in decisions about their care.

Accessible, convenient and flexible services, available promptly and equally to everyone where proper consultation means real influence on how services are delivered.

Safe, high quality, effective care delivered in modern clean hospitals and surgeries where clinical quality delivers excellent outcomes.

Well run, efficient services delivering best value for tax payers’ money where transparency allows proper scrutiny.

A steady improvement in health and reduction in inequalities between the most and the least deprived.

Involving, listening and being influenced by patients, the public and clinicians’ views.

The regional programme engaged clinicians and others from across the East Midlands. A variety of material setting out a direction for the development of services has been


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developed and an overall strategy document published18. This has been taken into account in developing the LLR vision.

2.2.3 The LLR Next Stage Review programme

Within the NHS East Midlands area, five “county-wide” Next Stage Review programmes were established to ensure a greater level of clinical and public engagement than is possible at regional level. The LLR programme focuses on the needs of Leicester, Leicestershire and Rutland19. It has been agreed that the Next Stage Review is the right vehicle for addressing all of the local drivers for change, but set within a national framework.

Therefore overarching aims of improvement across LLR have been set out in line with national and regional intentions. These are to ensure future services are:

Fair - equally available to all, taking full account of personal circumstances and diversity.

Personalised - tailored to the needs and wants of each individual, especially the most vulnerable and those in greatest need, providing access to services at the time and place of their choice.

Effective - focused on delivering outcomes for patients that are among the best in the world.

Safe - as safe as possible, giving patients and the public the confidence they need in the care they receive.

In the next section of the document, local work to redesign services in line with these overarching aims is discussed.

18 From Evidence to Excellence – Our clinical vision for patient care (NHS East Midlands, 2008).

19 The LLR NHS approach to this project, including programme timetable and governance

arrangements, is described in a separate Project Initiation Document available upon request.


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SECTION 3 : THE NEXT STAGE REVIEW PROGRAMME

This section of the document summarises the work of local clinical task groups and sets out an overarching vision for health care, which taken together have led to the formulation of some key principles for service development.

3.1 Clinical task groups

The LLR NHS’ Next Stage Review Programme is based on the work of eight clinical task groups (CTGs) corresponding to nationally specified areas of work. The work of the clinical task groups spans birth through to end of life, as shown below.

Figure 6 : LLR Our NHS Our Future Next Stage Review Clinical Task Groups

The CTGs consisted of multidisciplinary teams from all partner organisations across health and social care across LLR. Particular emphasis was given to ensuring that all work spanned crossed primary, secondary and tertiary care.

Each CTG was given a pack of supporting information, data and evidence on service improvement. Working with this, the CTGs prioritised a number of service changes, redesigned some care pathways, and documented their work.

Reports were drafted in January 2008 and finalised in March 2008. In addition to the original evidence pack, final CTG reports have been informed by regional workstream reports, NHS staff comments, and an external quality assurance process.

Public and patient involvement has also been central to the CTG work. Public discussion events were arranged so that the CTG proposals could be tested with representatives of the LLR population. (Some of the public discussion findings are set out in this section of the document, and engagement and consultation around service change is discussed further in section 4.)


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The outputs of each CTG are summarised below and then in more detail in Appendix 1 of this document. Original CTG reports are available via the public NHS web site http://www.eastmids.nhs.uk/ournhsourfuture 20.

3.2 The findings of the clinical task groups

3.2.1 Maternity and newborn services

To meet national standards and offer women across Leicester, Leicestershire and Rutland a genuine choice of place of birth, maternity and newborn services in LLR will need to improve the way these services are currently configured and delivered. Pressures from, for example Maternity Matters, Safer Child Birth, and the National Service Framework for Children’s, Young People, and Maternity Services and the need to offer more choice and flexibility to pregnant women present considerable challenges to current services and improvement will mean change.

The CTG focussed on the changes needed to respond to increased number of pregnancies and ensure future services remain sustainable, safe and effective21. The CTG recommends consolidating services to ensure specialist care is delivered in the most effective and efficient way for mothers and their families. The CTG will continue to support choice of birth, co-located midwifery-led units, stand alone birth centres, home birth and specialist acute site care.

The CTG’s vision for maternity and newborn care is to:

Deliver a high quality safe maternity and neonatal service.

Have maternity services which respond to public expectations, are rooted in evidence based practice and are easily accessible for the local population.

Develop maternity services that improve access and offer choice whilst ensuring safety of the chosen environment.

Deliver services with an appropriate workforce that meets all national guidance regarding working practices and professional standards. This will include further development of maternity care support workers.

Provide an integrated service between primary and secondary care, giving continuity of community midwife and involvement of the appropriate members of the multi-agency team as required. This will be developed by further integrated care pathways and models to support individualised care ensuring identification of social, cultural and medical needs.

Have an appropriate environment which is safe and fit for purpose and which

20 Internal NHS website.

21 Birth rates in LLR have increased by 16% over the last five years to 10,451 deliveries in 2007.

Greater demands for newborn intensive care are also being experienced. Birth rates are set to rise by 2% year on year.


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responds to the expectations of women and clinical need.

Consolidate and further develop the neonatal and fetal/ maternal services to meet the responsibilities of being the lead centre for the Central Newborn Network.

Have the capacity to care for babies requiring tertiary centre neonatal care, including a fully established transport service.

Have an appropriately trained and competent healthcare professional to provide maternity care.

The CTG applied their vision throughout the care pathway from pre-conception to postnatal care. The group’s proposals focused on improving access to services through providing increased choice and flexibility. Key themes were: shifting the focus of services away from hospital settings much more towards the community; and investment in and engagement with vulnerable groups, including women with mental health needs.

To deliver the vision, the CTG identified five priority areas summarised below.

Figure 7 : Maternity and newborn care CTG priorities

Develop multi-agency care pathways

Develop closer working relationships with commissioners and local stakeholders

Robust, integrated clinical governance systems Develop a consolidated specialist obstetric and neonatal unit

Integrated approach to choice, access and equality

Across these five priorities, the CTG identified the need for whole system integration focussed on:

Integrated care pathways, including primary care and community based services.

A multi-agency approach to the care of women and their families, linking in with improved communication across primary care teams, children’s centres and maternity services.

The introduction of a common assessment framework to facilitate early identification of needs and appropriate intervention.

In public discussions of the CTG proposals, members of the public supported changes design to provide a greater degree of choice and flexibility; extended out of hours provision; the concept of children’s centres (purpose built centres with midwives, links to social services and language support among other services); and the option of a home birth.

Members of the public advocated more mobile services; greater consideration of men in designing maternity and newborn services and more accessible information and help for fathers-to-be; better availability of information generally and access to it; home visits; continuity of care both before and after birth; and outreach focused on hard-to-reach groups such as people who do not speak English and teenagers.


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3.2.2 Children and young people’s services

Approximately 239,600 children and young people live in the Leicester, Leicestershire and Rutland. Children and young people represent approximately a quarter of the health economy’s population. The children and young people’s CTG stressed the importance of working for the family across institutional and agency boundaries. It also identified the need for integrated service planning, commissioning and provision. For this to work in reality services will need to truly focus on children and young people, not institutions, and pathways will need to be comprehensive rather than piecemeal.

The CTG recommended that all local stakeholders work together to debate and agree what ‘integration’ really means and to develop a model to take forward this approach. The dimensions of a whole systems model are illustrated below.

Figure 8 : Whole systems model for children’s and young people’s care

Conception Young Adulthood

Health and well being:

The NHS

contribution

Children who are ill Vulnerable Children

Health prevention and promotionSurveillance and screening

Parenting support and guidance

Early identification of risk

Primary CareAcute Care (including highly

specialist careLTCs (including children with

disability)CAMHS

Palliative care

Children in care/ children at risk

of abuseCare for children with disabilitiesCare for children at risk of social

exclusion

The CTG’s proposed model for future children and young people’s service provision, reflecting a whole systems approach, is illustrated below.


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Figure 9 : Overarching population model for integrated children and young people’s services in LLR

Primary Care Team in local primary care

settings

Child and family School and

children’s centres

Multi agency

assessment, e.g. CAF,

complex care

Approximately 80% of all out-patient and

diagnostic activity

delivered in community

settings

Ambulatory care for acute episodes and long-

term conditions

Local Hospital/Tertiary

Centre

Specialist care delivered in the community with appropriate support from the hospital acute care team and mental health

providers

Primary Care Team in local primary care

settings

Child and family School and

children’s centres

Multi agency

assessment, e.g. CAF,

complex care

Approximately 80% of all out-patient and

diagnostic activity

delivered in community

settings

Ambulatory care for acute episodes and long-

term conditions

Local Hospital/Tertiary

Centre

Specialist care delivered in the community with appropriate support from the hospital acute care team and mental health

providers

Again in line with national policy, the CTG recommended that the majority of children and young people’s care across LLR should be provided as close to home as possible, in local settings such as schools, children’s centres and primary care facilities. It also recognised evidence that where larger numbers of ill children are treated in a single service then paediatric acute care has better outcomes. The CTG recommended that, for inpatient care, the local NHS should ensure access to a specialist centre housing all local children’s services with expert staff and the specialist equipment and the resources needed to care for ill children.

In summary, the vision for children and young people’s services is:

To put children and young people first to enable them to live a healthy life and maximise their potential, through child and family focussed services. These must be delivered by a competent and skilled multi-agency workforce, as close to the child’s home as is appropriate within venues that are acceptable and accessible to children, young people and their families.

In practice this means that children and young people would be seen predominantly in the community close to their home. This means that much activity currently delivered in hospital settings (particularly outpatient care) would shift into the community. Whilst less complex illnesses can be seen as close to home as possible; service changes will need to take into account clinical co-location, financial efficiency and critical mass. Overall, the CTG recommended that all children and young people’s services across LLR should be child and family centred and delivered as close to home as possible. The report’s key themes are:


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There should be the development of an integrated children and young people’s service across health and local authorities including joint planning and commissioning. This will require integrated working between the hospital, community child health services and child and adolescent mental health services, which are currently separate health providers.

LLR needs to develop locally integrated services and seamless pathways for children across (physical and mental) health and local authorities.

Primary care teams should play a key role in the child’s pathway in terms of prevention, maintaining child health, and treatment. For children and young people who require specialist care, primary care teams should remain an active partner throughout the child’s journey.

Staying healthy and health promotion should be central to each pathway.

Services should be delivered as closely to the child and family as possible and delivered in a multi-agency way.

Some services should be delivered more centrally when outcomes are better in specialist tertiary units (e.g. oncology, neurosurgery).

The discharge from acute settings for children and young people with complex care needs should be seen as an issue that needs input from health, voluntary, education and social care. The complexity of this provision should not be used by any one partner to abrogate its responsibility in enabling the process to be as quick as possible. An example of this might be where a delay in housing adaptation prevents a child being rehabilitated into the community, or where a child cannot be offered respite through social care because of health’s inability to provide for the child’s ongoing medical needs.

In public discussions of the CTG proposals, members of the public supported the development of a specialist centre to house all local children’s services; shared information; and the development of a key worker role or ‘family liaison officer’ to co-ordinate all aspects of care.

Members of the public advocated a balance of local services with central services, recognising that travel for some specialist care is necessary; with aftercare provided in the child’s home or based in the local community wherever possible.

3.2.3 Staying healthy support and services

A major challenge is to improve the health of all individuals, significantly reducing the inequalities in health experience and life expectancy between those who are most healthy and those who are least healthy in LLR. Recognising that everyone is different and will have different needs at different times in their lives, the local NHS must help people to become healthy on their own terms and work with partners to create an environment that enables this.


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In recent years the need for the NHS to focus on its role in improving health and preventing disease has been highlighted many times22. Helping the local population to be healthier involves the LLR NHS in taking a leading role to:

Support individuals and communities to live healthier lives.

Make healthier choices easier for everyone.

Establish prevention programmes that reach all those at risk and in greatest need.

Improve, maintain and prevent as far as possible the deterioration in the health of those who have chronic and long term health conditions or mental health issues.

Together with partners, the local NHS has already achieved much in this area but significantly more is required. If health aspirations are to be achieved we must work closer with partners to systematically address current gaping inequalities in health across Leicester, Leicestershire and Rutland. This means implementing initiatives designed to directly improve health and ensuring equitable access to large-scale disease prevention services. It means assembling the evidence base for effective interventions and ensuring best practice recommendations are rapidly established throughout. As a precondition it means maintaining a comprehensive range of essential public health functions and services (including specific health protection and emergency planning services) and ensuring the resilience of the NHS for major incidents.

Central to the CTG proposals is that all NHS staff, and particularly all clinical health professionals, should provide support and advice to enable healthy living at every encounter with patients and the public. Every NHS contact offers an opportunity to improve health. The CTG emphasised the need for the local NHS to provide more systematic opportunities for the population to access tailored advice from health professionals about healthy living on an ongoing and routine basis.

If LLR is to achieve its aspirations for improved health, it will need to work constructively with partners to better understand how to reduce inequalities overall. It will need to work with local authority partners and other colleagues to influence the social, environmental and economic root causes of inequality and wider determinants of health.

The CTG recommended that to improve health and reduce health inequalities the local NHS must lead the work to add years to life and life to years. This focuses on:

Supporting personalised health programmes.

Maintaining a focus on inequalities.

Identifying incentives and levers within the NHS and Local Authorities to increase investment in prevention.

Realising the full potential of the local NHS to work in partnership and promote

22 For example in the Wanless Report, the Choosing Health White Paper, and the Our Health,

Our Care, Our Say White Paper.


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Better Health for All.

Combining the best possible prevention of ill health with the best possible treatment.

Supporting an ongoing commitment to full NHS engagement in action on the broader issues affecting health, particularly: economic development; education and the ability to learn; and environmental design.

The CTG analysis of the major causes of early death and ill health, and discussions with the public, led the group to recommend six key priority areas to improve the health of local residents. These are summarised below.

Figure 10 : Staying healthy priority areas

Reducing the number of smokers through smoking cessation and tobacco control

Improving the diet of the local population through healthy eating (and reducing obesity, cancer,

strokes and CVD)

Reducing the harmful effects caused by alcohol

Improving the physical activity of the local population (and reducing obesity, mental ill health,

CVD and strokes)

Commissioning known evidence-based preventive services as part of every Care

Pathway

Establishing a comprehensive local programme of vascular risk screening for the adult population

In public discussions of the CTG proposals, some members of the public supported a more pro-active and personalised healthy living communication strategy. Some believe that the most appropriate way of delivering healthy lifestyle advice is to have it personalised. Others suggested targeting children in schools and educating them in terms of a healthy lifestyle. Many supported detailed, structured health and / or fitness advice rather than generic advice.

3.2.4 Mental health and learning disabilities

The work of the mental health and learning disabilities CTG builds on a history of local engagement with stakeholders including service users and carers.

There is a high incidence of mental health illness across LLR. Prevalence of mental illness is highest in the most deprived areas. Social, economic, and psychological factors have significant impact on incidence, duration, and recovery from mental illness and on service use. These issues cut across each of the priority areas identified by the CTG.

The key themes of the CTG report are to modernise the model of care and facilities so as to transform community services to provide a clear pathway for service users and referrers and achieve excellence in inpatient services through an improved focus on the inpatient pathway and service user experience. The vision for the overall direction of mental health and learning disability services is based on the following principles, agreed by commissioners and other stakeholders in mental health and learning disability services:


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A shift in emphasis towards health promotion, illness prevention and early intervention.

The promotion of successful recovery.

The provision of services as close to home as possible, consistent with the achievement of high quality outcomes.

The redesign of care pathways to remove barriers to treatment, to make access to the right services easier and to ensure a better service user experience.

The provision of services in environments designed around the needs of service users and carers that offer genuine choice and empowerment.

Recognition of the diversity of communities and a commitment to delivering opportunities and services equitably.

The promotion of a pluralist network of provision, giving choice.

These principles reflect national policy and coincide with the emphases of the national Next Stage Review programme. They also underpin the Mental Health Charter developed across LLR. This charter is illustrated below and will be central to the future planning and provision of the mental health and learning disabilities services.

Figure 11 : Charter for mental health in Leicester, Leicestershire and Rutland


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Both the CTG and Leicestershire Partnership NHS Trust (in its future service strategy23) have identified an overarching approach to mental health and learning disabilities services across LLR. Significant service redesign of mental health services based on best practice and consultation with stakeholders (including service users and carers) is already taking place across the health and social care community. These changes will enable the local NHS to develop more responsive and accessible mental health services. Overarching plans include:

Consolidating services for working age adults and for older people (organic services) on single sites so as to establish centres of excellence with the highest standards of modern inpatient care and improved communication and access between services (including community and crisis services), all supported by best practice in clinical governance24.

Strengthening community services and developing a locality focused service model that:

– Integrates Trust services with wider health and social care services.

– Promotes easy access to services at a local level.

– Secures the development and provision of specialist skills and models of care to meet a wide range of service user needs.

The development of Primary Care Mental Health services is a local priority that will improve access and service responses to patients with common mental health problems. One in six people suffer from a common mental health problem. 90% of these people are managed entirely in primary care. The resources available to these people will be increased to provide local services that are readily accessible in primary care settings. These services will work to establish links between GP Practices and other local community provision including JobCentre Plus, education, sports, leisure and voluntary sector services with a view to promoting recovery and social inclusion, whilst in the longer term reducing stigma. This will include improvements in access to, and the delivery of, psychological therapies to people with common mental health problems.

Service users and carers across Leicester City Leicestershire and Rutland have consistently fed back that they see the availability of psychological therapies as a very important part of local mental health provision. Primary care mental health services will respond to this feedback for those patients with common mental health problems. Services will be developed in accordance with the guidance provided by the national Improving Access to Psychological Therapies Programme and as part of a strategic framework agreed by the two PCTs to provide therapeutic interventions and promote the

23 Available from the Trust.

24 Work is now being undertaken to identify the best location for the single sites taking account of the condition and development potential of existing facilities and the important connections that should be made with other clinical services.

services. Overarching plans include:

Consolidating services for working age adults and for older people (organic services) on single sites so as to establish centres of excellence with the highest standards of modern inpatient care and improved communication and access between services (including community and crisis services), all supported by best

24practice in clinical governance24.


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health and well-being of patients.

In the future this will mean that clear care pathways between services will support the service user’s journey, aid recovery and provide timely access to a range of services. There will be an increased emphasis on the need to develop health promotion, illness prevention, early intervention work, a pluralist network of provision and new ways of working. Working with health and social care partners there will be better levels of acute hospital, GP and primary care engagement in developing services and agreed pathways will be developed through involving different agencies and providers.

In public discussions of the CTG proposals, members of the public supported the principles of bringing specialisms and skills together; moving mental health services into the community; improved inter-agency communications; continuity of care and good communication, structured care plans and dedicated points of contact for each patient; targeted services and personalised care; with mental health care to focus not only on basic care and safety but on quality of life and happiness. .

3.2.5 Acute care

Over the past two and a half years secondary care emergency admissions in LLR have increased year on year. Analysis indicates that current use of secondary care emergency facilities is in the region of 14% above the expected level based on the age, gender, and deprivation profile of the local population. In addition, the National average percentage of people who are admitted to hospital having attended an acute hospital Emergency Department is 19.1%. In LLR, 26.5% of people currently attending UHL’s Emergency Department are admitted to hospital25.

The CTG vision is to provide accessible, prompt, and convenient care for the people who need NHS services urgently and only to admit those who need the specialist skills and facilities of acute hospital. Currently many people attend an acute hospital Emergency Department to get help with minor illnesses, minor injuries and repeat prescriptions. These people could get appropriate help and be treated more conveniently at their GP practice or in community services such as minor injury units or walk-in-centres.

The vision is to improve clinical outcomes and patient experience for all patients needing urgent health services, ranging from those who need help but do not need admitting to hospital to patients with more complex conditions, such as stroke or heart attack. To do this, we will:

Develop a whole system approach to care based on national policy and built upon multi-agency partnerships delivering individualised health and social care for all, ensuring that people move between Primary and Secondary care services in a seamless way.

Ensure equity of care and access across the whole health and social care community through integrated working between acute units, emergency treatment

25 Presentation to LCR Board 3

rd March 2008 on behalf of LLR Unscheduled Care Board.


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services, ambulance services, community hospitals, primary care, social services and the voluntary and independent sector.

Ensure the most appropriate primary care, community services and acute services are available across LLR so that patients can be treated at the right place, at the right time by the most appropriate clinician.

Harmonise services so that patients can follow the same clinical pathway regardless of the point at which they enter the service.

Develop a continuous process for public education to ensure that patients are signposted to the most appropriate service and where possible are encouraged to access primary care services including pharmacists.

Ensure all patients presenting as an emergency benefit from a proactive clinical management process (a care plan) with timely investigations, so that a diagnosis is reached (or potential diagnoses excluded) and definitive treatment begun quickly and efficiently. This should be the case regardless of where and when the patient first presents.

Enhance joint health and social care mental health teams so people with dementia and their families and carers receive the support they need.

Develop services to take into account, and respond to, the diverse cultural needs of individuals from different communities across LLR and cover a spectrum of care across all ages. Services will strive to include and support both patients and their carers in all aspects of the planning of their care, treatment, rehabilitation and on-going long term support.

Underpinning the CTG proposals is the principle that patients accessing urgent care require a 24 hour service that is consistent and responds promptly to their need. An overarching theme is to develop urgent care services in two key ways:

Develop local services that will enable patients to be seen closer to home, for example in minor injury units or by community based falls teams.

Develop centralised specialist services where evidence supports this centralisation and shows this saves lives and improves outcomes – for example in the case of heart attack and stroke services.

The figure below shows the CTG’s proposed specialist stroke service to improve care for those experiencing a stroke.


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Figure 12 : Specialist hyperacute stroke unit proposal

The LLR NHS faces a number of challenges in taking forward these proposals. Not least of these is that of current physical estate. Currently important emergency services that need to be co-located are spread across three acute hospital sites. This challenge is one the local NHS will particularly need to address to ensure best practice. Equally, proposals to move services out of acute settings will require significantly improved and enhanced access to primary care services.

In public discussions of the CTG proposals, members of the public supported the idea of a single point of access for emergency care; telephone advice services and the possibility of booking GP appointments through the internet via email or even through digital interactive television; increased use of walk-in centres (though knowledge of these is limited) and facilities at local hospitals; moving care from secondary to primary care settings where appropriate; local community minor injuries units; and the importance of educating the public about the appropriate use of NHS services (in particular when to use A&E).

3.2.6 Planned care

The CTG proposals for planned care services across LLR are closely aligned to recommendations across all CTGs – they are based on the principle that care should be provided as close to the home as possible where this is practical and it is safe and cost effective to do so. They also recognise that, in some cases, the local NHS will need to centralise some specialist services to ensure scarce skill, expertise and technology are available when and where they are most needed, and where they will have the most positive impact on clinical outcomes for patients.

FAST (Face Arm Speech Test)

Within 1 hour

Hyperacute

Stroke Unit

CT scan within 30 mins

Thrombolysis within 30 mins

Major Acute Hospital

Hyperacute

Stroke Unit



Specialist Hospital

Neurology, neurosurgery�

�� Rescue

Advice

carotid doppler & MRI scan

within 24 hrs

echocardiography + 24 hr ECG

within 48hrs

Hyperacute Stroke Unit




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The vision for planned care services is that:

Care should be fair (equitable), personalised, of high quality (expert, safe, timely, improving clinical outcomes and patient experience), cost effective and acceptable to patients.

Timely diagnosis and treatment and/or agreement on a management plan should be supported as close to the point of referral as possible.

Direct access to key support services e.g. physiotherapy services; orthotics services; diagnostic services within agreed protocols should support earlier treatment and avoid unnecessary referral to hospital.

Where it is necessary for a patient to attend the hospital, diagnosis and agreement on management of the plan should be delivered on a one-stop basis.

Direct listing should be available for specified surgical pathways that require hospital admission to avoid unnecessary delay in treatment.

Where surgical treatment is required, discharge planning should start before admission by looking ahead to the discharge and recovery period. Information on discharge/recovery should be provided before treatment to help allay patient and family fears.

Where hospital admission is required, the time spent in the acute setting should be as short as possible facilitated as necessary by early supported discharge.

The CTG focussed on eight priority care pathways26 and made a number of recommendations for improvements to each pathway. Over and above these recommendations, the CTG identified a number of generic issues that cut across all planned care pathways and will need attention. These include:

Establishing clinics within community locations.

Developing an education programme for GPs as part of a clinical network.

Developing ‘prehabilitation’ as part of the care pathways for specific patients.

Integrating I.T. systems and developing a single/ shared electronic document.

Rotating/ training staff across the healthcare community and developing in-reach/ outreach/ linked outpatient services.

Developing a single point of access for community services.

Interim placements for patients unable to go home who do not require nursing/ therapy input; for example, people with housing problems or who are non-weight

26 Rectal bleeding, hernia, tonsillectomy, dermatology, vasectomy, haematuria, direct access

physiotherapy and direct access orthotics.


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bearing.

In public discussions of the CTG proposals, members of the public supported improving elective treatment through better planning, which could lead to a better in-patient experience, and would encourage a faster recovery period; patients being informed of the entire care process in advance; receiving aftercare closer to home when possible; spending less time in hospital, reducing patient isolation; and more collaboration and coordination to ensure closer and more efficient communication.

3.2.7 Long term conditions

People with Long Term Conditions (LTCs) are amongst the biggest users of health care. Across the UK patients with a LTC account for 80% of all GP consultations. The incidence of LTCs within LLR is projected to grow in the future in line with the rise in the elderly population, particularly in Leicestershire and Rutland.

LTC support and management requires much attention. Every effort must be made to prevent LTCs where possible. There are clear links between lifestyle behaviours and the incidence of some LTCs. For instance, smoking increases the likelihood of developing cancer and obesity increases the chances of suffering from Type II diabetes. The proposed approach to supporting healthy living has been described earlier. It will be vital to link this approach into the management and support of LTCs.

The needs of people with LTCs have been recognised in recent national policy. Local proposals support the thrust of national policy and seek to put this into practice in LLR. This includes supporting patients so that they can become equipped to manage the day to day aspects of their condition themselves. Effective self-management of LTCs will help patients maintain control of their lives.

The CTG vision for LTC care across LLR is to:

Implement optimum care pathways and optimise patient information.

In taking forward this vision, the CTG identified six clinical priorities: chronic kidney disease; chronic obstructive pulmonary disease/ asthma; chronic heart disease/ heart failure; diabetes; neurological conditions such as Parkinson’s disease and multiple sclerosis; and rheumatology and arthritis. Within local services for each of these clinical conditions there are a number of generic issues we must address to improve services. In particular the CTG was keen to consider (across all LTC pathways):

Improving the primary / secondary care interface and communication.

Developing standardised patient materials/ guidance – every patient with a LTC should have access to an agreed, quality assured set of information to improve knowledge about their disease and the resources available to them.

Focusing on prevention – identifying at risk groups, early detection, diagnosis, ongoing management plans, rehabilitation and palliative/ end of life care.

Extending care to incorporate a multi-disciplinary team including therapies, social care, community equipment etc. This needs to be a key feature of any generic


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LTC care pathway.

Professional inputs and outputs offering seamless movement within the pathway supported by good communication.

Processes enabling secondary care to communicate effectively with primary care and “let go safely” of those patients for whom follow up and care planning should appropriately be delivered in the primary care setting.

In public discussions of the CTG proposals, members of the public supported a personalised care plan which would give details of their condition, treatment and care, offering a greater level of information on long-term health conditions, and this may enable ‘self-care’; shared and accessible patient notes; patients having up-to-date and accessible information for their particular health condition; and a long-term healthcare plan allowing people to take responsibility for their health.

3.2.8 End of life care

People at the end of life often require support and care from a number of different services. Services need to be personalised and provide increased choice as part of end of life care. In particular people should be supported to choose where to die, and to die with dignity and respect. Their needs should be addressed with sensitivity.

The end of life care CTG’s vision for end of life care is:

To develop end of life care services that are patient focused and able to meet individual need (including the needs of carers), particularly enabling choice in decisions about care and preferred place of death. Services should be equitable safe and able to meet the needs of a diverse population.

Care at the end of life should be supported by standards and outcome measures to ensure it is effectively meeting the needs of the local population and helping to build and

maintain public confidence in the services provided. The key outcome is to achieve a ‘good’ death for all patients and their families/carers.

In particular the CTG recommended the use of nationally approved end of life care frameworks and pathways and the establishment of community support teams to support patients to die at home (if this is their wish) or in a care home if this is their choice. This will mean ensuring that patients are identified as being at the end of their lives and encouraging regular discussion in relation to where individuals want to be cared for, where they would like to die, and what care and support they and their families / carers need during the last year of life, with particular attention given to the last few days of life.

Within this overall aim, the CTG identified seven priority areas:

Raising public awareness in relation to death and dying and end of life care services.

Implementing advanced care planning for all patients on the end of life register.

Developing co-ordinated care for all care pathways.


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Supporting families at all stages of the end of life care pathway including bereavement care.

Developing out of hours services that support end of life care.

Developing an end of life care education and training strategy across LLR.

In public discussions of the CTG proposals, members of the public supported the personalisation of end of life health services; initiatives to improve dignity and respect; more local care; better continuity of care; improved communication and sensitivity to cultural differences surrounding death.

3.2.9 Themes running through all Clinical Task Groups

People see the NHS as a whole. Through the CTGs work this has been reinforced by that fact that some significant themes were raised by all Clinical Task Group work and indeed ‘cut across’ the whole LLR NHS. These cross cutting themes include clinical governance, infection control, hospital cleanliness, workforce development and education and training. These important themes are central to all service improvement across LLR. Due to their relevance across the board they will be taken forward by a clinical forum comprising the clinical leads of each CTG. Cross-cutting themes are described further in Appendix 2.

3.3 Leicester, Leicestershire and Rutland NHS vision

Drawing together all of the findings and recommendations of the CTGs, the local NHS proposed ten year vision, for adults and children and for physical and mental health services is:


The figure below shows how the LLR NHS sees this vision becoming a reality across Leicester, Leicestershire and Rutland.


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Figure 13 : The Leicester, Leicestershire and Rutland NHS vision

Fair Personalised

Effective Safe

Wide range of community based/

local health services

Effective high quality acute and specialist care

Support to make healthy choices and self-care

Accessible and high qualityprimary care services

The key themes of this vision are that:

Patients, the public and communities will be fully involved in improving their health and the quality of local health services.

Health services will be fair, effective, personalised and safe.

Across Leicester, Leicestershire and Rutland people will be supported to make healthy choices, stay healthy and self-care.

Services will need to become increasingly integrated across primary care and secondary care and with local authorities.

Services will be provided locally where possible and centralised where necessary – there will be more care available closer to home. At the same time more specialist care will be provided in high quality, specialist centres of excellence for those services where centralisation improves outcomes.

People will be able to access the right services – when they need them.

The themes have been translated into seven principles to work to as a whole health system:


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Table 2 : LLR NHS health service principles

Ensure excellent clinical outcomes for patients

This means:

Delivering services within effective clinical governance and risk management frameworks

Basing care on best evidence, innovation and technology

Developing services that are recognised nationally and internationally for quality

Ensuring care is delivered by the most appropriate professional, working as part of highly trained and motivated teams

Put patients and the public at the heart of service delivery and involve them in its planning

This means:

Designing services around the needs of patients

Basing services on personalised care

Listening to patients and the public, involving them and acting on what they have to say

Promoting dignity and respect throughout the patient experience

Patients should experience joined up care pathways

Care should be co-ordinated across the whole health and social care system, as well as welfare services such as housing and employment

Safeguarding the particular needs and risks for vulnerable patients

Enable patients where possible to take responsibility for their own health and well-being and the treatment they receive

Through:

Encouraging self care and supporting people to stay well

Focusing on prevention, early intervention, and well being

Focus on reducing health inequalities

By:

Targeting and tailoring services to local needs

Responding to changing demographics and epidemiology

Ensuring opportunities and services are delivered fairly to diverse communities

Offer a real choice of easily accessible services

By:

Promoting a pluralist network of provision

Enabling people to choose from a range of care options as close to home as possible

Delivering fair and equitable access to the best range of services possible

Delivering services as locally as possible and in the safest, most cost effective and clinically appropriate locations

Providing services in clean, modern environments designed


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around the needs of patients

Make best use of resources

Through:

Delivering best value to ensure that the health gain of every NHS pound is maximised

Ensuring financially robust and sustainable organisations, each focussed on excellence in all it does

Balancing service resilience and plurality

Ensuring best use of resources, including workforce and estate

Improving commissioning

Impact on the wider determinants of health and well being

By:

Influencing public opinion against unhealthy behaviour such as smoking, binge drinking, poor diet and sedentary life style

Adopting a holistic approach to health by addressing environmental factors such as poor housing and debt

Promoting personalised behaviour change programmes

Working with social care and voluntary sector partners on issues we know influence health and well-being

The principles have been derived from a vision that in turn reflects the work undertaken by the CTGs. Each proposal for service change will be tested against these principles. To illustrate this, some proposed changes are set out in the following section.


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SECTION 4 : WAY FORWARD

In this section of the document, some ways in which the principles can be met through service change proposals are set out, and some related strategic planning work is described. The means by which the Next Stage Review will be taken forward are then discussed, including some immediate service improvements locally and regionally, forward planning, continued patient engagement and partnership working. Equality impact is discussed.

4.1 Application of the vision and principles

4.1.1 CTG proposals

A variety of changes have been proposed by the CTGs, as discussed in section 3 of this document. Some proposals are described here, showing how each of the principles for change can be met.

Ensure excellent clinical outcomes for patients

Many strokes are preventable. For those who suffer stroke it has a major impact on life. Stroke is one of the top three causes of death in England and the leading cause of adult disability. Patients who have early, fast access to comprehensive and specialist stroke services and are cared for in a defined stroke unit with access to specialist rehabilitation are more likely to survive, have fewer complications, are more likely to regain independence, will spend less time in hospital and at a lower overall cost of care. Currently LLR’s stroke patients receive differing quality of acute stroke care depending on the time of their presentation and the correct recognition of stroke symptoms by the ambulance service. Extension and development of the acute stroke service to include a round-the-clock operation, co-location with the Emergency Department, and a capacity for endovascular diagnosis and intervention with neurosurgery will ensure the provision of the highest quality evidence-based care for all acute stroke patients. Integrated models of stroke rehabilitation across the hospital/community interface including early supported domiciliary discharge schemes will result in higher levels of patient independence, higher levels of patient and carer satisfaction and a reduction in the length of hospital stay. The diagram below illustrates the pathway that is being developed across LLR.


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Figure 14 : New stroke pathway for better outcomes

Suspected Stroke Event

NHS Direct GP 999 Emergency Department

FAST positive 999, Priority A ambulance

Immediate specialist assessment

Immediate neuroimaging

Thrombolysis and other acute therapies including

endovascular intervention and neurosurgery

24/7 specialist medical input

7/7 medical and therapy input

Coordinated rehabilitation from the day of admission

Provided pts medically fit enough

discharge to Local stroke Rehab unitsDay 8-14 Other stroke patients.

County: St Luke’s Market

Harborough or Snibston Stroke

Unit Coalville

City: Rehabilitation ward

at LGH

Discharge Destinations (these can

occur at any time in the pathway)

Home +/ Package of care (POC)

Home with ESDS (Early supported Discharge

Scheme)

To family + -POC and ESDS

Re-ablement bed in Residential Home

Non-specialist rehab bed

Residential home

Nursing home

All discharged

Patients

supported by a

Community

Stroke Team

(Average length of stay 28 days, some lot shorter, some longer)

Day 1

Day 8+/-1

Day 8-28

MDT stroke Specialist rehab and medical input

Strokes coded A22/A23

Stroke Unit at LRI


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Put patients and the public at the heart of service delivery and involve them in its planning

Commissioners and providers of mental health and learning disability services are committed to the involvement of service users and carers in strategic planning arrangements and as individual’s in their own care arrangements.

The PCTs and Local Authorities have commissioned service user and carer involvement groups (People’s Forum and Carer’s Action in the counties and Open Assembly@Genesis in the city). Those groups make links with a wide range of service users and carers to seek their views about current and future services, which are fed into planning arrangements.

Work is also underway through a user led pilot research project to capture user experience of local services. Those views are now being analysed and will be used in the development of future improvements to current services.

Both Leicestershire and Rutland Local Implementation Team (LIT) and Leicester City LIT, including the two PCTs, Leicestershire Partnership NHS Trust and Local Authorities have signed up to the Mental Health Charter as described on page 27 above.

Mental health and learning disability services are provided through person-centred planning arrangements for both service users and their carers. This starts with an assessment of the person’s needs, which informs the development of a care plan (or for carers a support plan) that is regularly reviewed by a care coordinator or key worker. The user and/or carer are involved at all stages of this process the aim being that their needs are central to the process and services that they receive.

The service user and/or carer are involved at all stages of this process the aim being that their needs are central to the process and services that they receive.

Each service user and/or carer can expect to receive mental health services that are sensitive to their needs and which are delivered in accordance with the Mental Health Charter.

The NHS and Local Authorities have developed integrated service arrangements for those people with more complex needs. This means that health and social care staff work together to provide seamless, holistic care that responds to individual needs and promotes recovery and social inclusion. This includes assistance with and links to other services such as housing, employment, education, sport and leisure to help each person integrate into community and mainstream activities.

Enable patients where possible to take responsibility for their own health and well-being and the treatment they receive

The long term conditions CTG examined opportunities for patients with all LTCs to benefit from important improvements to self care, and specifically considered:

1. How patients and professionals could change the way they work together in the future so that patients can become more active partners in how their care is planned and delivered.


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2. How patients themselves can gain a better understanding of their condition and how best to manage it on a day to day basis.

Today, patients with diabetes benefit from a wide range of resources to support their care including a hand held patient folder and dedicated patient education sessions. Both of these have been specifically designed to improve their understanding of their condition, track their progress, and help them get the best from contact with the various professionals who care for them in hospital, community services or primary care.

Patients with other long term conditions receive a mixture of support and information from professionals and other sources. They often have to research information themselves about their condition, or have to book an appointment via their GP or consultant to address particular problems for questions and concerns that could be solved by access to better support, information and care planning in the community. They can also find it difficult to find information about local support groups or determine which national organisations or websites provide information most applicable to their condition.

Patients with less prevalent LTCs find it even more difficult to access local information or support, and the professionals caring for them are less likely to be experts in these types of conditions, than in the more prevalent LTCs like COPD, CHD or diabetes.

For the future the CTG has therefore prioritised the provision of an approved set of information for every patient with a long term condition as a key quality enhancement to local LTC services. This information can build up over time to suit the individual’s needs and be stored in the hand held patient folder - so that patients, carers and family members will have a hard copy of this information to refer to at home or during appointments. It is intended that this folder will provide a selection of information that has been approved by local clinicians/professionals working collaboratively across health, social care and voluntary sector agencies. It will likely include:

Information to support people at initial diagnosis.

How to access support groups.

How to access educational opportunities.

Information about who is caring for the patient and how to contact them.

What to do if the condition deteriorates, including out of hours support.

Information about any medicines and equipment.

The folder will also help patients to schedule appointments, prepare for appointments, record information or questions which might be shared at appointments plus document information about the goals agreed within their care plan and how they will be working to achieve them.


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Focus on reducing health inequalities

Maternity and newborn services can be developed to ensure services focus on reducing health inequalities. The CTG looked at ways in which this could be achieved by:

Providing targeted service to the most vulnerable and marginalised groups, e.g. specialist midwives for pregnant teenagers, women with alcohol and substance misuse problem, homelessness etc.

Providing a locality based and easily accessible named midwife to encourage engagement with hard-to-reach groups.

Improving access to services though co-location and innovative service delivery models (e.g. teenage pregnancy care provision).

Exploring options to address the communication needs of a multi-lingual community.

Training and promote accessible breast feeding peer support counsellors.

Improving access to breast feeding peer support counsellors.

Working in partnership with other agencies (e.g. education, youth services etc) to reduce teenage contraception rates.

Developing a joint smoking cessation care pathway and carbon monoxide protocol, so that women and their families are referred and able to access support and nicotine replacement therapy to enable them to quit smoking.

Currently, maternity care can be provided by numerous agencies in a variety of different locations. While there are examples of good multi-disciplinary team working, there is also evidence of fragmented care and pathways for a proportion of women and their families. Services are often provided in fixed locations and constrained by geographical or funding barriers.

The CTG’s proposed future model of care (see figure below) sees maternity services and newborn care as part of a continuum. Mothers and their families are at the centre of care packages designed around their needs. Co-located services and integrated responses ensure continuity of care.


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Figure 15 : Future model of care – maternity and newborn services

Mother and family

Lead professional,

local service

Appropriate care

pathway

Relevant involvement

of

MDT

Direct access to midwife

Needs identified

Specialist care delivery

Offer a real choice of easily accessible services

End of life care27 services can be developed to offer greater choice to patients. Currently, patients are often not on an EOLC register – particularly those with long-term conditions such as congestive heart failure. Even those that are may not be provided with appropriate packages of care or may not be given the opportunity to discuss the different options and make choices in relation to their care. They do not have an advanced care plan so are not asked where they would like to be cared for or where they would like to die. They may not have a key worker and often do not know who to call in an emergency situation.

In the future, all eligible28 patients will be placed on an EOLC register. The primary care team will discuss their care needs regularly and appropriate care packages will be put in place. They will have an advanced care plan which clearly outlines where they wish to be cared for after all options have been discussed. They will have a key worker and out of hours contact number.

Currently, in a crisis situation, near to end of life the patient/carer calls 999 and the person is admitted to hospital where they often die within 24/48 hours of admission. This also affects patients in care homes as current services are not always equipped to deal

27 This relates to ‘planned’ EOLC for patients with cancer or long term conditions.

28 Identified via the ‘surprise’ question – ‘would you be surprised if this patient died within the next

12 months?’


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with patients at the EOL. Current infrastructures are not robust enough to truly support patient choice as there is not adequate availability of skilled health care professionals or access to equipment, drugs or services, which can help support carers. This reduces the likelihood of enabling patients to die at home in a care home or in a community hospital setting.

In the future, crisis situations should be avoided due to forward planning. Emergency admissions to acute hospitals will therefore be reduced. Patients will be cared for and die in the place of their choice, which will often be home with appropriate support or in a hospice, community hospital or care home. Patients or carers will be much more involved in decisions and be able to make informed choices about where they wish to be cared for and where they would like to die. Support services will be available to enable choice particularly in relation to dying at home, in sheltered accommodation, in a care home or community hospital and will include “24/7” access to skilled professionals, equipment, drugs, information and carer or health professional support.

Planned care is offered across more than 40 specialties covering a vast range of problems. Specialties predominantly fall into two categories: those managing relatively simple and common problems (high volume/relatively low complexity) and those managing rarer and more complex problems (low volume/high complexity/specialised). Most patients present with relatively common problems. Here there is great scope to offer more choice of easily accessible services. These services will meet set criteria around safety, appropriate training, joint working and governance. As an example, rectal bleeding is a common problem, with an estimated 16-33% of people experiencing it at some point in their lives29. Although no sinister cause is found in the majority of cases, it is worrying and is the type of condition where people want a diagnosis quickly.

Currently most patients presenting with isolated rectal bleeding have a flexible sigmoidoscopy in hospital regardless of age. The National Institute for Health and Clinical Excellence (NICE) recommends only those aged 60 years and over with persistent isolated rectal bleeding symptoms should automatically be referred to the hospital.

The table below summarises the type of choices that can be made available to patients following this pathway taking into account the evidence outlined above.

29 Mathew J et al. Postgrad Med J 2004; 80: 38-40.


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Table 3 : Proposed planned care pathway – rectal bleeding

Age Referral Criteria

<45 The risk of serious pathology in this group is very small.

Patients in this category should be conservatively managed in primary care without the need for a sigmoidoscopy or referral to hospital (‘watchful waiting’).

If the problem persists, patients could be offered the choice of referral to a local GP service which can perform sigmoidoscopy +/- banding of piles (the most common cause of rectal bleeding). Alternatively the patient might choose to be referred to a medic or surgeon in the acute hospital.

45 - 60 If symptoms are less than 6 weeks, then patients should be managed conservatively in primary care (‘watchful waiting’).

If symptoms persist for more than 6 weeks, then patients can be offered the choice or referral to either an approved GP with specialist interest or a colorectal surgeon at UHL.

>60 Patients can be offered the choice of referral to either an approved GP with specialist interest or a colorectal surgeon at UHL. The referral should be made on an urgent basis as the risk of bowel cancer is higher in this group.

This care pathway is an example that shows how choice can be offered whilst still delivering on the key principles underpinning planned care and offering a model of care that is consistent with research evidence.

Make best use of resources

Currently, children’s services are commissioned and delivered by a number of different agencies across health and the local authorities. Although these organisations currently work well together, structural and institutional boundaries have to be overcome and act as a barrier to more co-ordinated and effective health delivery. The result leads to overlapping services in some areas, and gaps in others.

In the future, services will be commissioned in a holistic and comprehensive way using programmes of care rather than through fragmented episodes of care. Organisations will deliver care that is integrated around the needs of the child and family wherever possible. This will result in resources being utilised with maximum efficiency by reducing overlap and closing gaps in existing health provision. Using the existing relatively scarce children’s workforce co-operatively across the agencies, better skill-mix and increased quality of care is achieved. By delivering care close to home where possible and centralising where necessary, best use of health and local authority estate is attained and improves access and equity of health care.

As a result the following changes will occur.


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Table 4 : Children’s services – improved use of resources

Current Issues New Approach

Many consultations or health care visits with repetition of information. Patients are not always seen by the right clinician at the right time.

Single points of access ensure timely access to appropriate services and speedier passage through pathways of care.

Continued hospitalisation beyond need for inpatient services, so care not close to home.

The workforce practices across acute and community settings, permitting earlier discharge and allowing acute care to focus on the sickest children

Limited pool of skilled workforce Integrated workforce across agencies and settings share skills and expertise to improve outcomes and quality of care. This in turn will improve retention of staff.

Transition difficulties Transition between existing providers will be automatic as a function of integrated delivery which will save time and resources.

Limited joint planning and commissioning Integrated commissioning across health and the local authorities will ensure comprehensive programmes of care that take account of access and equity of healthcare. This will lead to best use of finite financial resources.

Impact on the wider determinants of health and well being

Impacting on the wider determinants of health and well-being - making healthier choices easier for everyone – means addressing the range of different influences on health, including creating incentives for stakeholders to keep more people healthy, and promoting personalised behaviour change programmes. It also includes those strategic actions which look beyond individual lifestyles and health services, to factors that clearly could be modified by sustained public action, and a clear message that these factors and health are inter-related. Examples considered by the CTG include working with partners to secure a reduction in tobacco marketing, working to improve environmental design for increased physical activity, supporting education and the ability to learn, addressing environmental factors in poor health.

Our actions will include:

Maintaining a focus on inequalities in health.

Systematic health equity audits, equity profiling, health needs analysis and reviews of evidence to support commissioning by the local NHS and Local Authorities and public policy development to reduce inequalities.

Identifying incentives and levers within the NHS and Local Authorities to increase investment in prevention.

Combining the best possible prevention of ill health with the best possible


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treatment, including supporting personalised health programmes.

Supporting an ongoing commitment to full NHS engagement in action on the broader issues affecting health, particularly: economic development; education and the ability to learn; and environmental design.

4.2 Organisational strategies

Much work to take forward local delivery is already underway within LLR. As stated at the beginning of this document, this will be enhanced and supplemented by the local NHS vision. Current local strategic planning work includes:

Leicester County and Rutland PCT’s review of the rural counties’ current community health services, including community hospitals. Community hospitals will support the delivery of care much closer to home and will provide an increased volume and range of services organised around five hub hospitals; provide two walk-in centres; offer a greater range of minor injuries and day case services; and provide for extended palliative care.

The Leicestershire Partnership NHS Trust’s 2012 strategy is based on developing person centred, holistic models of care to support recovery. This will support both the consolidation of highly specialist services within modern, fit for purpose inpatient facilities and the development of locality based community services much closer to patients’ homes and within a refocused and rationalised estate.

Leicester City PCT’s strategic plans to address, in particular, the city’s major challenges around primary and community care service provision. The PCT is developing a strategy for targeted investment in primary care services and facilities designed to bring about substantial improvements in access, choice, innovation, service quality and improved patient involvement and satisfaction over the next ten years.

The University Hospitals of Leicester (UHL) NHS Trust is undertaking strategic planning to review how it best provides specialist acute care to the people of LLR and beyond. At the heart of this planning is the concept of ‘UHL Central’ and ‘UHL Local’. This mirrors the concept of centralise where necessary and localise where possible. ‘UHL Central’ describes those specialist services which have to be provided in an acute hospital – such as major abdominal surgery. This is mainly due to what the experts describe as ‘critical mass’, where it is safer for a patient to see a surgeon who is used to and familiar with a particular condition than a surgeon who may only see one or two cases per year. ‘UHL Local’ describes those specialist services which are either currently provided or could be provided across LLR, rather than just in the acute hospitals. Such services could be provided by other providers than UHL. However, UHL believes that it will be able to provide some specialist services more locally to patients. This would combine specialist expertise and continuity of care that can be provided locally and in the centre. In other words it would be possible for a patient to see the same UHL consultant in a setting near their home as they would when they come to the acute hospital.


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East Midlands Ambulance Service NHS Trust’s (EMAS) strategic business plan to provide a high quality, effective 24/7 mobile healthcare resource fully integrated into all aspects of emergency, urgent and non emergency healthcare. Many 999 calls do not need an emergency response or transportation to hospital. Through increased clinical triage and the appropriate mobile response, the LLR NHS could increase its ability to provide immediate care in the home or at the scene without the need to go to hospital. For patients with emergency and life threatening conditions, the focus needs to be to take them to the right place, first time. This is particularly needed in the management of stroke, myocardial infarction (heart attack) and major trauma. In addition, by integrating EMAS into the management of long term conditions, intermediate and end of life care the NHS could more fully help to meet the mobile health needs of the LLR patient population.

The Next Stage Review has enabled the local NHS to align the above major pieces of work already underway and begin to bring these together as a whole system vision to transform the way that care is delivered.

4.3 Some immediate changes

Not all of the change proposals need formal consultation. Many recommendations are about enhancing existing services or improving productivity. These recommendations can be taken forward though normal NHS planning processes. Where practical these have been taken forward so as to start making a real difference as quickly as possible, building on the momentum and energy created by the Next Stage Review programme to date.

Some early proposed changes, resulting from the Next Stage Review work and related initiatives are set out in accompanying documents to Excellence for All: Next Steps for Improving Health Services and Leicestershire County and Rutland PCT’s Community Health Services Review.

In addition to local quick wins, the national Next Stage Review contains targeted funding for local developments which are now underway. These are summarised in the table below.

Table 5 : Implementing the National Interim Report

Next Stage Review Interim Report Action in LLR

Increase the number of GP practices in those 25% of PCTs with the poorest provision

Three new GP Practices are being commissioned in Leicester City PCT.

At least 50% of GP practices to have weekend and at least one evening opening

LCRCT and LCPCT have both completed baseline assessments of additional opening hours in preparation for this.

150 new GP led health centres to be developed nationally

LCRCT and LCPCT have both submitted state of readiness assessments to East Midlands SHA.

Implementing MRSA screening for all planned hospital admissions in 2008/09.

Implemented MRSA screening for all planned hospital admissions 2008/09.


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4.4 Regional services

Across the East Midlands Operational Plans 2008/09 will include the following Next Stage Review regional recommendations:

Patients with long-term conditions, such as diabetes, will receive a personalised healthcare plan.

Each PCT will complete the “what to do in a crisis” part of the care plan for patients at the end of their life, living with a long term condition, or living with a mental illness.

All patients with respiratory problems who smoke and who are admitted to hospital will receive smoking cessation support as part of their admission.

Ambulance protocols will be developed so that the ambulance service can make the right decisions as to where they take patients.

These recommendations apply to LLR and will be reflected in plans for service change and improvement.

Some of the most complex and specialist NHS services operate within clinical networks that transcend LLR boundaries and span the East Midlands region and beyond. This particularly applies to some aspects of trauma care, highly specialist mental health services, vascular, neurology, stroke care, perinatal care, and specialist children’s services such as paediatric oncology.

Specialist commissioning arrangements are being put into place to set out future requirements in relation to the following areas:

Drawing up national standards for Specialised Children’s Services and Bone Marrow Transplant (BMT).

Developing network arrangements for specialised burn care services, including prioritisation of national funding allocations.

Establishing commissioning frameworks for mental health and learning disability services (forensic low, medium and high secure, perinatal psychiatry, eating disorders and CAMHS Tier 4 services).

Prioritising neonatal and paediatric critical services, specialised cancer services and spinal services.

Similarly, there are some issues, such as the development of primary angioplasty, which though not complex and highly specialised, are also being addressed regionally.

In 2006/2007 more than 12,000 patients across the East Midlands were admitted to hospital with heart attacks. Between a third and two thirds of heart attacks take place in the community. Prompt access to the best treatment is therefore essential and evidence tells us that these patients should either go straight to a specialist hospital for primary angioplasty (widening an artery) if they live within 90 minutes of the specialist hospital or,


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if they live further away, they should receive thrombolysis (clot busting drugs) in the ambulance or hospital. The diagram below shows how the model of care will work for chest pain and angioplasty across LLR and the East Midlands.

Figure 16 : Chest Pain / Angioplasty Model of Care

�

��

��

Specialist HospitalSpecialist Hospital

Angioplasty

Thrombolysis

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��

��

��

��

��

��

��

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Local HospitalLocal Hospital

CCU

Major Acute

Hospital

Major Acute

Hospital

CCU

Major Acute

Hospital

Major Acute

Hospital

CCU

From chest pain to angioplasty

In order for this to work, we will devise a simple system which enables the ambulance service to know where to take a patient in need of this service and for them to be able to pre-alert the appropriate selected centre including one at University Hospitals of

Leicester.30

Figure 17 : How this will improve care for…a woman with chest pain

Now Future

Elsie has chest pain. She dials 999 and an ambulance comes within eight minutes. The paramedics carry out an ECG and give Elsie clot busting drugs. They take her to the nearest acute hospital where further tests are carried out. Elsie is then transferred to a specialist hospital for angioplasty.

Elsie dials 999 and an ambulance comes within eight minutes. The paramedics carry out an ECG. As Elsie lives less than 90 minutes way from a specialist hospital which can provide primary angioplasty 24/7, she is taken there rather than the local acute hospital.

30 RCP; Myocardial Infarction Audit Project; How the NHS Manages Heart Attacks; 2007


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Trauma remains the fourth leading cause of death in western countries and the leading cause of death in the first four decades of life. As the incidence of trauma is particularly high in the younger population, an average of 36 life years is lost for every trauma death.31

Along with the East Midlands region as a whole, LLR will adopt the recommendations of ‘Better Care for the Severely Injured,’ Royal College of Surgeons (2000) and ‘Trauma Who Cares’, the National Confidential Enquiry into Patient Outcome and Death (Nov 2007). This will involve the reorganisation of trauma services locally as nationally so that no severely injured patients are admitted inappropriately to hospitals not properly equipped or staffed to provide a timely intervention. It will mean the 24 hour presence of a consultant-led trauma team. All patients with major head injuries will go immediately to a hospital with critical care/neurosurgical facilities. A system of advance notification between ambulance service and hospital will be used as illustrated in the figure below.

Figure 18 : Proposed model of care – major trauma

Specialist HospitalSpecialist Hospital

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Major Acute

Hospital

Major Acute

Hospital

��

Major Acute

Hospital

Major Acute

Hospital

��


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Emergency

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Emergency

Ambulance

Selected Patients

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Transfer if

indicated

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The local NHS is committed to working within these regional processes and networks in the future development of these services and will play its part in their development.

31 Trauma: who cares? A report by NCEPOD; 2007


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4.5 Forward planning

The LLR NHS is at the start of a three year planning cycle. As described above, in year one (2008/09) plans have focussed on quick wins, local priorities and national targeted areas (i.e. those in section 4.2 above). Over the coming years, the LLR Next Stage Review programme will continue to influence and underpin Annual Operational Plans and strategic and operational planning processes. It is also likely to influence:

Local Area Agreements (LAAs) and Local Strategic Partnerships (LSPs).

Local authority service provision, particularly as it relates to clinical pathways under consideration within the clinical task groups.

Neighbouring health communities undertaking similar service reviews, particularly in terms of specialist services that cross county boundaries.

Changes in national policy.

Engagement with local universities and training institutions.

Some of the service change proposals discussed in this document, and in Appendix 1, may have implications for the configuration of health facilities across LLR. There is more investigative work and more public engagement to be undertaken before we can be clear on what the options for, for example, future acute hospitals configuration might need to be. However, some early thinking is set out in Next Steps for Improving Health Services.

4.6 Engagement and consultation

As stated earlier, a number of pubic engagement initiatives have already been undertaken on the Next Stage Review. Engaging and consulting with the public about the LLR vision (and any options that we may face in achieving change) is an important part of the journey to improved local health services. Over 300 representative members of the public have taken part in discussion events32 (some of their views were summarised earlier in section 3) and many others have been engaged through contact with representative groups, clinical networks, Patient and Public Involvement Forums (PPIFs), programme boards and through Our NHS Our Future open events.

In parallel (though beginning earlier), the Leicestershire County and Rutland PCT review of community health services included regularly providing information to the public, local councils, the voluntary sector and other parts of the NHS through regular newsletters, public meetings, websites, and requests for feedback. In addition, stakeholders on local groups set up to develop proposals for community hospitals included members of the public, clinicians, managers and representatives of adult social care.

Throughout August and September 2007 the PCT gathered feedback from individuals, interest groups and organisations across Leicestershire and Rutland (including the county council, district councils and parish councils) on how services could be

32 Reports on each of the Next Stage Review discussion events facilitated by MORI are available

at www.haveyoursayLLR.nhs.uk.


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developed. More than 700 responses were received and taken into account in the development of proposals. Further feedback was received in October and November. In addition to these engagement activities, a third document will be launched with the public on 16th June 2008. The Leicestershire County and Rutland PCT Community Health Services Review has been developed to formally consult with patients, the public and partners on future proposals for community health services within Leicestershire and Rutland Counties. Formal consultation will end on 5th October 2008.

For the Next Stage Review good practice set out in Quality Assurance of Major Changes to Service Provision33 will be followed. We are committed to being open and transparent in all our activities and will respond to queries from members of the public openly and in accordance with the Freedom of Information Act (2000) and the NHS Code of Openness. The Next Stage Review programme is built around the following steps for engagement:

Pre-consultation – through the local NHS working together to develop a vision it has developed a robust case for change. In doing so there has been an extensive dialogue with a wide range of key stakeholders including the public and their representatives, patients and carers, clinicians and NHS staff. The approach to engagement during this phase of the programme has been described above.

Local clinical involvement – the local NHS embarked upon this process through the work of the Next Stage Review CTGs. Through the ongoing work of the Next Stage Review programme as a whole, clinical involvement will be continued at every stage.

The decision-making process – The Next Stage Review programme has been set up as a formal programme, with appropriate governance arrangements built into the programme’s structure. A project board to oversee the programme is made up of senior level representation from all appropriate bodies to ensure proper sign-off of each element of the programme. Throughout the process there will be close liaison with overview and scrutiny bodies, as is normal good practice.

Implementation of the required changes will be monitored with representatives of patients, the public, clinicians and staff, including a progress and quality review.

The next step in this process will be launching a summary of the health community’s Excellence for All vision, together with two associated documents: a Next Steps document which describes local NHS proposals that will begin to deliver the vision over the next 12 – 18 months in further detail and the Leicestershire County and Rutland PCT Community Health Services Review which has been developed to formally consult with patients, the public and partners on future proposals for community health services within Leicestershire and Rutland Counties. Excellence for All and the Next Steps will be launched with the public on 12th July 2008. Throughout July, August, and September we plan to engage widely with the public on the content of these documents. We want to listen to our public’s views and to use these to then inform and shape our vision and our plans. Following the engagement period ending on 5th October 2008 we will

33 Department of Health, 2007


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consider all comments and feedback and review our work to date in the light of this. The public, our patients and our partners will be fully engaged in an ongoing dialogue with the LLR health community. The Leicestershire County and Rutland PCT Community Health Services Review will be launched on 16th June 2008 and will formally consult with patients, the public and partners on future proposals for community health services within Leicestershire and Rutland Counties. Formal consultation will end on 5th October 2008.

When we have completed the first period of engagement and consultation as described above we will undertake a full, independent evaluation of our engagement and consultation activities and ensure any lessons learnt are then applied to our ongoing work to realise our vision. As we develop further plans we will engage and involve our patients, the public and our partners in further dialogue and debate.

4.7 Working with partners

Realising the LLR NHS vision will only be achieved by everyone working together. At an organisational level the cornerstone of the planned approach will be for the local NHS to work in partnership with businesses, the voluntary sector, and other public sector organisations such as local authorities. These partners will be essential to our success. Joint working is central to our vision.

The long standing association between De Montfort University, the University of Leicester and the NHS will remain of particular value and importance. It will play an important role in the major change programme that the Next Stage Review programme covers. The intention is to design teaching and research opportunities into modern, high quality health service delivery.

To realise this vision all health care professionals will need to be equipped with the skills required by the future health service and those who use our services. This will need the local NHS to work in ever closer partnership with the many important institutions that support the training and development of the broad range of health care professionals.

4.8 Ongoing local accountability

The Next Stage Review must deliver the changes that local people and local clinicians have discussed, debated, and agreed. It must improve health and local health services. At all times, the LLR health community must be held accountable to and involve local people in achieving these goals. The governance structure for ongoing work is currently being developed to ensure the programme is effectively governed as it continues on its journey towards Excellence for All. Regular updates with the Joint and local Overview and Scrutiny Committees will be central to this process.

4.9 Equality impact assessment

As well as being good practice, Equality Impact Assessments are fundamentally a legal obligation of public authorities. Their purpose is to ensure those authorities eliminate unlawful discrimination, promote equality of opportunity and promote good relations between the communities affected by legislation.

Currently statutory obligations require Equality Impact Assessments on the grounds of


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disability, gender and race. However, good practice and health service aspirations encourage us to carry out Equality Impact Assessments on the grounds of age, faith and belief, and sexual orientation in addition.

This vision document has been screened to assess the need for a full Equality Impact Assessment and as a result of this screening the LLR health community has agreed that the proposals put forward by the CTGs will be subject to a full Equality Impact Assessment in the course of developing the proposals further in preparation for implementation. As the Next Stage Review programme progresses and new proposals for health services change emerge, these too will be subjected to the same process of assessment.

The process of Equality Impact Assessment will use community engagement and consultation processes. These processes will give particular focus to those most adversely affected by current service provision.


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SECTION 5 : CONCLUSION

This document marks a milestone in the local Next Stage Review process. It has been used to develop an NHS-wide vision for health services which has the formal sign up of LLR NHS Boards and clinicians across the health community. Such broad sign up will be essential in realising our vision, which will now be tested even more widely across a broad range of local public, patients, organisational partners, clinicians, and other health professionals and stakeholders.

While current services across LLR go some way to meeting local needs, there are number of reason why services now need to change. We believe the people of LLR deserve the best. The proposed local ten year vision for the NHS is:


At the heart of this vision is a focus on reducing health inequalities, on improving health and well-being across the board, and on improving the quality of all our health services. This vision is wide ranging and cuts across all commissioners and providers of NHS services within LLR. It will change the nature of care provided in a range of settings: in primary care and community facilities; in ambulances; in patients’ homes; and in acute hospitals. These changes will need to be delivered as a coherent, integrated plan.

Only by everyone working together will the local vision be realised. The approach to this work will be underpinned by ensuring effective relationships with partners and that the public and patients continue to inform NHS thinking, help to develop ideas and options for change and help to implement agreed service changes. The next step in this journey will be to widely engage with the public about the proposed vision and the options to realise the vision following the launch of this document in July. We will also consult with the public on a range of proposed changes to Leicestershire and Rutland Counties’ community services, including community hospitals. Our focus on meaningfully engaging with our partners, patients, and the public on our proposed vision and its delivery is the next step on our important journey towards Excellence for All.


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APPENDIX 1 : CLINICALTASK GROUP PROPOSALS


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Figure 19 : Maternity and newborn care CTG proposals

Key proposals What does best practice look like?

Pre-conceptual care and health promotion

Provide appropriate advice and support – A range of activities to help women and their families make decisions about their lifestyle to ensure optimum health of the mother and baby. This includes providing information regarding diet, smoking, alcohol, as well as specific advice, such as genetic screening.

Develop multi-agency care pathways - to ensure that women and their families can access appropriate pre-conceptual and health promotion services in various settings, including Sure Start Children’s Centres, GP practices and hospitals.

Provide services for vulnerable women – Appropriate services to improve birth outcomes for vulnerable women and women in special circumstances, such as teenage pregnancy, mental health, asylum seekers and women whose first language is not English.

Antenatal care Support community based care - for all normal pregnancies with referral of women and foetuses with health needs to specialists.

Provide midwives in accessible locations - for example in supermarkets or pharmacies, in order to better improve access. Access to midwives in these locations will be well publicised.

Provide appropriate advice and support – on breast feeding, dietary, smoking and lifestyle advice should be provided.

Provide appropriate advice and support - all women will have the support of a named midwife throughout their pregnancy and their care will be provided as close to home as possible.

Offer comprehensive screening/ diagnostic service - in line with national guidelines and supported by written information.

Birth

Ensure choice of birth setting - women and families will be supported to make an informed choice on the place of birth, taking into account their individual needs. Provide one to one care - for women during labour and birth. Ensure the safe staffing of birth settings. Provide neonatal services - to support service provision and supplement maternity services on a single site.

Postnatal Care Provide seamless and integrated post natal care.

Offer mental health support - this is critical to women with mental health needs and is complementary to maternity services.


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Offer a choice of setting – to women in terms of where they receive post natal care.

Provide appropriate advice and support – on breast feeding and screening tests for their babies.

Improving neonatal services

Provide perinatal (neonatal) care as part of a managed clinical network and on a single site.

Improve access to neonatal care - for premature and sick babies. Including a 24/7 retrieval service. Develop generic roles across organisations - including the development of specialist midwifery roles and advanced neonatal nurse practitioners, supporting vulnerable women with issues such as HIV and teenage pregnancy.

Provide 24/7 neonatal transport – contracted separately from neonatal intensive care to ensure that neonatal staffing is not compromised when transport take places.

Develop integrated primary and secondary services – for the sick neonate post discharge. This will also require additional support in community services.

Provide enhanced GP guidance and education - in order to provide ongoing care of babies who have been treated in neonatal services.


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Figure 20 : Children’s Services CTG proposals

Key proposals

What does best practice look like?

Whole system integration

Develop an integrated children’s service across health and Local Authorities including joint planning and commissioning – including an integrated, electronic, health record.

Develop a single call access system for emergency/ urgent care services for children.

Ensure closer working between GPs and paediatricians.

Develop a network of interlinked complementary services with flexible funding arrangements to ensure that each child has access to the most appropriate service.

Ensure clear protocols and pathways for referral to appropriate levels of care with algorithms for management.

Improve joined up working between local authority partners, PCT public health and (mental and physical) health care providers including sharing information.

Services should be commissioned as part of a comprehensive pathway of care.

Prevention Identify vulnerable children as soon as possible, including prior to birth.

Families to receive healthy living advice on every contact with local services, particularly focused on reductions in child obesity and harmful effects of smoking and alcohol abuse.

Easily accessible, local child friendly environments for children to be seen by all professionals.

All services where appropriate to focus on improving and maintaining children’s health and well-being along with the prevention of ill health in line with the outcomes from the Government’s Every Child matters report.

Public health professionals with an expertise in children’s services should be developed.

Develop a more comprehensive child health surveillance programme.

Assessment and interventions

Further develop needs led multi-agency assessment / child development services.

Localise care where possible, centralise where necessary. This means that the majority of specialist care will be delivered in the child’s community wherever possible; only acute care and highly specialised/technological care will be delivered from a hospital setting. For example, early intervention and treatment should be carried out locally, including outreach services, ambulatory care for ill children and


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those with long term conditions and palliative care.

Children’s ED to work together with children’s assessment unit (CAU) at UHL.

UHL to co-locate Children’s ED and CAU and rotate staff between ED and the Children’s hospital.

Develop a children’s ambulatory service where staff rotate across community and acute settings to develop a system for crisis aversion.

Increase capacity for community nursing and rotation of posts between hospital and community settings.

Adolescence Further develop adolescent services to facilitate planning of appropriate services.

Ensure adult services have transitions targets.


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Figure 21 : Staying Healthy CTG proposals


Promote and enable more physical activity as part of a healthier lifestyle

Introduce ‘healthy lifestyle’ referrals for support and intervention by the NHS if evidence based and cost effective for those with a specified range of signs, symptoms, risk factors or disease

Systematic contractual and commissioning arrangements to encourage all health care providers to refer specified patients to physical activity services as above

Extended workplace wellness programmes with robust physical activity element integrated with the Active Together programme

Extend the formal network of health trainers, employed by other sectors, and with their training and network support provided by the NHS

Comprehensive active lifestyles programmes including supporting behaviour change through targeted action.

Focus on improving activity in children and young people

Use the opportunity of the 2012 Olympics to generate widespread engagement of the population in physical activity programmes

Promote and facilitate more healthy eating as part of a healthier lifestyle

Use of evidence-based personalised behaviour change programmes to encourage healthy eating and increased physical activity

Systematic implementation of NICE guidance on prevention & management of overweight and obesity in primary and secondary healthcare services

Focus on improving the diet of children and young people, through effective action with mothers, families and schools

Support Stop Smoking services and tobacco control

Use evidence-based and targeted campaigns to reduce smoking before, during and after pregnancy

Invest in infrastructure, skills and capacity of local specialist stop smoking services and tobacco control activity

All health care providers to proactively refer all patients who smoke to Stop Smoking Services

Institute brief intervention on smoking during all primary care encounters and support enhanced commissioning for integrated brief interventions targeted at all smokers

Introduce systematic non-NHS based brief intervention delivered by agencies such as social care, citizen’s advice bureau, and debt counselling


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Provide specific and effective services to targeted patient and vulnerable groups including all smokers who are hospital inpatients, patients with respiratory problems, pregnant women, children and young people

Identify and provide proactive smoking cessation services for all healthcare staff who smoke

Work with our partners to reduce the availability and supply of tobacco to children

Work with our partnership to reduce the supply of smuggled and counterfeit tobacco

Work with our partners to lobby nationally to secure a reduction in tobacco marketing by manufacturers and increased regulation and enforcement

Establish programme of action on Alcohol

Institute systematic, evidence-based brief intervention for alcohol during all primary care encounters

Support commissioning for evidence-based treatment services for alcohol on a scale sufficient to meet population need

Work with key Stakeholders and Crime and Disorder Reduction Partnerships (CDRP) to create alcohol-free zones and integrate visible enforcement programmes with schools and community based interventions

Commission an appropriate mix of general and specialist alcohol treatment services provided locally

Promote effective screening for alcohol harm in hospitals, prisons, and mental health facilities etc and onward referral to appropriate interventions.

Commission brief interventions in all A&E departments and intensive counselling for hospitalised patients

Joint Action with Partners to establish healthy environments

Actively support economic development of LLR with partners as better health is a means to achieve better economic growth and economic choices can assist in achieving better health

The NHS should support education and the ability to learn as a mechanism to achieve better health and improve access and use of health care services. The primary focus should be to support the academic content of curricula in securing high educational attainment.

Work closely on environmental design with partners to establish personnel, estate and housing plans that facilitate increased levels of walking, cycling and use of public transport., including the development of open spaces


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Secure an effective response to excess seasonal deaths.

Change food procurement and vending patterns in NHS and other work premises

Undertake a comprehensive oral health needs analysis and systematic evidence-based review of effective prevention and treatment.

Joint strategic oral health needs analysis undertaken, identifying levels of need for prevention, treatment and care pathways, with particular attention on the level of need in children and vulnerable groups.

Systematically establish the evidence base for effective prevention, treatment and care pathways for oral health and define minimum quality standards, including dental service access and availability to achieve Vital Sign commitments within the Local Operating Plans.

Consult widely, particularly with public, on options for evidence based prevention and treatment interventions, including consideration of the role of fluoridation of water supplies as a prevention measure.

Apply all commissioning and quality levers to rapidly implement outcomes from consultations


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Figure 22 : Mental Health and Learning Disabilities CTG proposals


Specialist Learning Disabilities services

Embed the current national Policy within the service model.

Design care pathways that work across the whole health and social care system and the independent sector.

Ensure access to mainstream services for people with Leaning Difficulties.

Develop a single point of access.

Implement the Green Light Tool Kit (i.e. access to Mental Health Services).

Delivery of psychological therapies

Ensure a Primary Care Mental Health Service is established and equipped to provide a range of therapies to patients in the community, including: -

More psychological therapies as part of a stepped care approach;

Services to promote the health and well-being of patients;

Advice and training to clinicians and other members of Primary Care Teams;

Links between Practices and local community provision including JobCentre Plus, statutory, voluntary and independent sector services with a view to promoting recovery and social inclusion, and in the longer term reducing stigma.

A Project team has been set up to develop a clear specification for the new service. Following that the Leicestershire County and Rutland PCT will apply the appropriate rules on contestability to the new service so that all possible providers of the service are dealt with fairly. The re-commissioned service should be available to patients in 2009/10.

Integrated locality services

Identify and establish clear care pathways.

Provide a locally responsive service as near as possible to the person in the community.

Ensure MDTs (Multi Disciplinary Teams) are based in the community.

Develop clear points of access and referral routes to and between services.


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Clinical networks Implement clinical networks that enable local treatment for the many and specialist care for the few who need this service – this will mean that clinical care is provided with an appropriate level of expertise to all service users.

Ensure clinical networks enable personalised, efficient and effective care pathways covering a spectrum from prevention through to the most severe and complex mental health problems.

Inpatient services Ensure the quality of inpatient areas and regularly monitor this.

Ensure meaningful and therapeutic activity plans are developed for all inpatients.

Standardise the approach to written information for service users.

Standardise the approach to early discharge.

Integrate assessments and care planning.

Emergency Department (ED) attendance of those with mental health issues

Agree a policy regarding operational interface between ED and Leicester Partnership Trust’s crisis service and increased crisis input into ED.

Develop primary care focus on frequent ED attenders to help avoid presentation.

Work towards developing an information system that can share information easily across organisations.


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Figure 23 : Acute Care CTG proposals


Differentiated Care34 – Stroke Pathway

Ensure patient and professional education - to raise awareness of services and ensure patients and professionals have a better understanding of best service to access and when.

Establish 24/7 acute stroke service - in a single centre with neurology in a location accessible to ED and imaging, ensuring sufficient therapy resources and space. Rapid access to scanning is required.

Develop a 24/ 7 Transient Ischaemic Attack (TIA) Service - People who experience a TIA need a rapid specialist assessment at a one-stop service. In order to develop one-stop clinics there needs to be investment in resources i.e. specialist stroke staff and access to investigations and results.

Develop a 24/7 Thrombolysis Service - Specialist Stroke Services should be able to deliver intravenous thrombolysis, throughout the 24-hour period.

Implement an Early Supported Discharge Scheme (ESDS) - ESDS are designed to allow for the early discharge of stroke patients to their own home with on going rehabilitation at home. They are time limited, not for the long-term management of stroke patients, which comes under the remit of NSF for Long Term Conditions.

Develop Community Stroke Teams (CST) - Community Stroke Teams provide support and information to patients and carers as well as the co-ordination of services across health and social care. They can organise therapy and review on discharge from hospital or Early Supported Discharge Teams, providing access to community based services over the long term.

Ensure adequate and appropriate Psychology Services - Psychological services for both emotional adjustment and cognitive rehabilitation should be integral to stroke services from post acute assessment through to support in community/vocational settings. They should be available in all parts of care pathways.

Ensure Family and Carer Support – In order to provide an equitable service the proposal is for two Family Carer Support Workers each to be part of the proposed community teams at the Rehabilitation Units in Market Harborough & Coalville Community Hospitals.

34 Differentiated care can be likened to a care pathway where healthcare resources are defined

around the needs of a readily identifiable patient group, for example a person experiencing a stroke or a heart attack.


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Differentiated Care – Chest Pain and Breathlessness

Develop a 24/7 Primary PCI service – to run in conjunction with Rescue PCI and in parallel to Thrombolysis (especially PHT).

Develop an Integrated COPD pathway – incorporating community based programmes, management plans to support COPD patients within General Practice, an education pathway and an Oxygen assessment service.

Develop Segmented Elevation Myocardinal Elevation (STEMI) patient management – associated with national supported development of pulmonary angioplasty. Ensure primary angioplasty provided at UHL.

Develop ambulatory care chest pain service.

Develop/increase cardio-pulmonary rehabilitation and anti-coagulation services in the community.

Differentiated Care - Dementia

Establish an Older Persons Liaison Psychiatric Service (LPS) based in the UHL ED – to provide rapid psychiatric assessment of appropriate older people with dementia, delirium and other mental health problems on UHL wards, clinical decisions units, and within the ED and to ensure a joint model of direct care for older people with co-existing physical and mental health problems.

Undifferentiated35 care

Provide a single point of access – for access to hospital for all patients needing acute care to ensure that all emergency admissions are triaged by a clinician and the best pathway is determined.

Develop a co-located ED, Primary Care Centre and Emergency Dental Service - with 24/7 senior decision makers at the front door, i.e. an emergency healthcare village staffed by a mixture of ED physicians, GPs, and other specialists.

Clinical teams to assess all patients on admission to assessment units – to ensure patients are on the most appropriate pathway (acute care or in a community setting).

Create direct access to outpatient clinics – allow GPs and ED to refer patients for emergency outpatient assessments. Also enable

35 Undifferentiated care is the term applied to patients who present with a range of clinical

conditions that cannot be easily diagnosed into a single patient pathway. Typically these patients present with multiple symptoms and need expert diagnosis before they can be guided to the appropriate pathway. This places emphasis on the need to have highly expert clinicians and diagnostic tests available at the very point the patient comes into contact with the health service, Without this, there is a risk that such patients may experience unnecessary delays before conclusive diagnosis and treatment plans are made.


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telephone access to specialist advice for GPs and ED consultants.

Establish 24/7 access to diagnostics – including CT, MRI and pathology.

Establish alternatives to admission – available via a navigation hub accessed by single point of access number. (to include daily acute medicine clinic, GP direct booking, urgent OPD, urgent investigations, good telephone access for GPs to specialists, good links to community care, information sharing on the capability and availability of community resources and access to social care).

Introduce Liaison Psychiatric Service for older people - based in UHL ED.

Patients that present at ED that do not require admission

Develop community services - to ensure 24/7 access for referrals from UHL.

Extend GP access –and develop a GP-led health centre in each PCT.

Develop an A&E bounce back facility - allowing patients with minor ailments to be referred to a GP appointment if appropriate.

Develop East Midlands Ambulance Service (EMAS) pathways - to enhance non-conveyance of patients to the ED. This includes developing emergency care practitioners within localities.

Develop Minor Injury Units and roll out minor ailment services across the County - to improve access for patients with minor injuries or illnesses.

Develop Community Outreach Workers – to link with the Alcohol Liaison Nurse in ED.

Significantly extend the role of community pharmacy - wide range of initiatives that could see community pharmacists more actively involved in avoiding ED attendance.


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Figure 24 : Planned Care CTG proposals


Patient Choice • Supported by more effective information along the whole care pathway to understand the implications of different decisions/ treatments.

• Introduce options which give increased patient choice and avoid the need for patients to physically attend appointments if this is not necessary – e.g. telephone consultations where clinically appropriate.

Care Pathways • Integrated care pathway for a condition/ group of conditions to be shared across the whole health care community from pre-op to recovery. (To include voluntary sector, leisure centres etc where appropriate).

• Key features of the care pathway include:

• Details on a daily basis the patient pathway and responsibilities.

• Defines patient outcomes on discharge.

• Signposts patients based on needs/ criteria to the appropriate rehabilitation/ support on discharge from the acute sector.

• Timely access to services at all stages.

• Pathway audited across the health care community, deviations reviewed and processes amend as required.

Communication/ Language

• Communicate in preferred format / wide range available e.g. DVD, CD, paper, email, Braille etc.

Patient support/ Health promotion (pre and post intervention – as well as along the clinical pathway)

• Use of the voluntary services/ leisure centres etc.

• Cardio respiratory- support and health promotion, promotion of active lifestyle post acute intervention.

Diagnostics • Timely access to diagnostics.

• Provide wider access to diagnostics within agreed protocols to inform the decision on referral.

Pre-operative planning

• Prehabilitation for identified patients e.g. weight loss, impaired mobility etc.


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Procedures • For those surgical procedures where best practice indicates day surgery should be the default, these surgical procedures to be performed on a daycase basis in the majority of cases.

Discharge planning pre-operatively and discharge

• Identification of post-op needs:

• One stop pre-operative shop.

• Use of screening tool/ patient questionnaire.

• Avoid duplication, shared proforma- to include medical, social status, and discharge planning.

• Identification of equipment needs. Where last minute equipment is required ensure same day delivery.

• Identification of social service needs.

• Equipment ordered and delivered.

• Potential social service needs identified and planned - housing issues identified and actions commenced.

• Potential discharge venue identified.

• Patient information: Describes likely patient pathway including length of stay, when patient will mobilise etc, to develop patient’s expectations.

• Therapy/ nurse lead.

• Responsive patient transport.

• Timely TTOS - dispense day before discharge.

• Range of discharge options available according to patients needs e.g. rehabilitation, intermediate care nursing home, residential home.

• Interim placements for patients not requiring nursing/ therapy input but unable to return home e.g. housing issues, non-weight bearing.

• S.O.S contact- single telephone number.


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Figure 25 : LTC CTG proposals


Empowered and informed patients

• Standardise education for staff and patients and a single individualised care plan for all patients with LTCs – develop protocols for issuing information prescriptions.

• Standardise mechanism and timing for patients receiving targeted information.

• Effective self management support including generic patient education programmes to develop self management and disease specific self management skills (DAPNE, DESMOND, Breathe Easy Groups etc).

Well co-ordinated team based care

• Teams should comprise a diverse workforce including GPs, specialist nurses and specialists and educators.

• Effective functional and psychosocial MDT assessment.

• Standardised education for staff and patients to include clinical supervision for extended roles.

Effective treatment

• Development of an initial management plan including communicating the diagnosis, lifestyle and patient education, care planning and depression assessment.

• Ongoing management plans including self management, structured, quality assured education, biomedical measures, medication reviews, surveillance for complications, care planning etc.

Real time patient data

• Develop systems to ensure ease of access for advice/ support to health professionals across all LTC pathways.

• Introduce a ‘clinical navigator’ tool for all LTCs including email access to professionals for advice.

• Develop a single point of reference for GP’s, nurses and allied professionals.

• Develop a directory of available services across city and county to facilitate easy contact for referrals.

• Minimise duplication of letters, results, and patient information – improve the processes for transferring information between primary and secondary care (particularly clinical letters).

• All patients with a LTC should have a disease specific and individualised patient held record/ information care plan.


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Rehabilitation • Proposals should be aligned to recommendations rising from the Planned Care CTG above.

Palliative Care • Proposals should be aligned to recommendations rising from the End of Life Care CTG below.


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Figure 26 : End of Life Care CTG proposals


Public awareness

• Public awareness strategy should be developed which results in the availability of appropriate information for the general public in relation to death and dying and EOLC provision and outlines initiatives, which can help, raise awareness amongst different communities and age groups across LLR.

• Public awareness campaign – nationally driven.

Assessment and care planning

• Advanced care planning (ACP) to be implemented for all patients once placed on the (GSF) EOL register.

• Agreed holistic assessment to be developed which incorporates ACP and advanced decisions to refuse treatment.

• Carers’ needs identified separately to the patient to ensure an honest and open discussion.

• MDT EOLC plan for all patients entering residential/nursing homes.

• MDT established to identify and discuss young people’s transition from children to adult services.

• Regular MDT meetings to discuss care needs during the last year(s) of life.

Co-ordination of care

• Coordinated (cross boundary) care pathway needed for EOLC across LLR.

• Practices to use GSF trigger question (would you be surprised if this patient were to die in the next 12 months) to identify patients with long term conditions who should be placed on the (GSF) EOL register.

• Joint (PCT/LA) commissioning required along patient pathways informed by PCT EOLC baseline review.

• Better communication systems needed with a strategy developed outlining plans to integrate health and social IT systems across LLR.

• Standards and outcome measures need to be agreed by the PCTs for each stage of the pathway.

• Use of guidelines outlined in the Association for Children’s Palliative Care Transitional Care Pathway.

• Implementation of patient held records while awaiting more integrated IT infrastructure.

• Identified key worker for all stages of the pathway.

• Shared LLR wide Do Not resuscitate (DNAR) forms.


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Last few days of life/ care after death

• Support for families/carers is needed at all stages of the pathway including bereavement care.

• Bereavement ‘policy’ (service specification/standards) for LLR with services commissioned in line with this.

Out-of-hours services

• GPs led OOH services working across localities.

• Access to social support out of hours.

• Hospice at Home 24/7 plus increased resource for Marie Curie.

• Development of specialist GP OOH services.

• Specialist advice available OOH (formal service which can be accessed by all).

• Formal agreement re drugs access needed – list of drugs, pharmacists and OOH services available.

Education and training

• EOLC education and training strategy required for pre and post registration training programmes for all disciplines across LLR.

• Rolling training programme for all staff (including GPs) including education of OOH GPs of services available and how to get expert advice.

• Training embedded in pre and post reg courses for all disciplines with mandatory component for medical staff (communication/symptom control).

• Increased targeted training for staff in all care settings.

• Advanced communication skills training and other relevant courses – e.g. CRUSE.


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APPENDIX 2 : CROSS CUTTING THEMES


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Overview

An overview of identified cross-cutting themes by category is illustrated in the figure below and then discussed in further detail in the following text.

Figure 27 : Overview - cross cutting themes


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Cross cutting patient/ clinical pathway themes

Cancer

Cancer is one of the major causes of death in most developed countries. It affects one in three of the UK population and kills one in four. Its incidence continues to rise36. It is predominantly a disease of the elderly37 and, as a consequence of the UK’s increasingly elderly population, it is estimated that there will be an average 16% increase in new cancer cases over the next 10 years38.

Cancer is one of the NHS’ central priorities. Over the last decade, a number of key policy and guidance documents have been developed with the intention of reforming UK cancer care. A framework for the future provision of cancer services has been established. The strategic intention is that by 2010 five-year survival rates for cancer in England and Wales will compare with the best in Europe. The national cancer framework is informed by the following key documents:

A Policy Framework for Commissioning Cancer Services (the Calman-Hine Report).

The NHS Cancer Plan July 2000.

Improving Outcomes Guidance 1999-2005.

National Radiotherapy Advisory Group (NRAG) Report to Ministers February 2007.

Cancer Reform Strategy December 2007

The Cancer Reform Strategy intends to ensure increased choice for cancer patients and stronger service commissioning. It focuses on moving care from inpatient to outpatient settings and from hospital to community settings.”39 There is an increased focus on

36 There were over 233,600 new cases of cancer in England in 2004. The four most common

cancers – breast, lung, bowel, and prostate – accounted for just over half of these new cases of cancer (excluding non-melanoma skin cancer). Breast cancer accounts for 32% of cancer cases amongst women whilst prostate cancer accounts for 25% of cancer cases amongst men (Getting it right for people with cancer: Clinical Case for Change – Report by Professor Mike Richards, National Cancer Director, May 2007).

37 Only 0.5% of cases registered in 2004 were children (aged under 15) and only 26% were in

people aged under 60 (Getting it right for people with cancer: Clinical Case for Change – Report by Professor Mike Richards, National Cancer Director, May 2007).

38 This equates to over 238,000 new cases of cancer per annum in England by 2016 (Getting it

right for people with cancer: Clinical Case for Change – Report by Professor Mike Richards, National Cancer Director, May 2007).

39 Professor Mike Richards, National Cancer Director, 19

th December 2006, Further details on the

Cancer Reform Strategy, http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_063569


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patient experience and on improving access, particularly travel times, to services. This strategy, combined with the demands of an ageing population, presents a significant challenge for health services across the UK, as for our local health economy. Treatments are also becoming more costly. However, we know that we can also increase our efficiency in service delivery. Across the work of our CTGs this means:

Focussing on prevention and early detection through expansion of our breast screening programme and establishing a rectal bleeding service and bowel screening.

Ensuring we screen all our population including those with mental health illnesses and / or learning disabilities.

Managing some cancers, as well as the effects of some treatments, as long term conditions.

Managing the longer term effects of disease and / or treatment on children who have experienced cancer and ensuring appropriate transition services as a child with cancer becomes an adult with cancer.

Extending the work of the Decisions at Life’s End (DALE) project to ensure people with cancer are not admitted to hospital unnecessarily at the end of their life and are supported to die with dignity in the setting of their choice.

Achieving the 31 and 62 day cancer care pathways across our planned care pathways and reducing the average length of stay for some admissions.

Developing best practice acute pathways for those with brain tumours.

The link between mental and physical health

Our wellbeing involves a complex interaction between our physical state of health and our mental health. For all of us, one may affect the other and so the links between mental and physical health issues need to be taken into account by service providers consistently. For example:

People living with severe and enduring mental health issues can find access to other health services difficult. They may feel excluded from, or may become disengaged from, treatment. This can result in undiagnosed illness or exacerbation of an existing condition. The GP Quality and Outcomes Framework (QOF) objective aims to ensure all those with serious mental illness have assess to an annual health check. Providing these checks and maintaining information is an important first step. However, the ongoing participation of mental health service users in other appropriate health services needs to be a shared objective across community mental health services and primary care. To support this work, we must make every effort ensure that all residents are registered with a GP.

Mental health service users with a dual diagnosis of mental health problems and alcohol and/or substance misuse are very likely to encounter serious physical health problems as a result of their substance misuse and of the consequent lifestyle. They may become frequent attenders at hospital Emergency


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Departments or to their GP surgery. We need to ensure that primary care practitioners are trained to recognise such patients when they present and that we have referral pathways in place to address issues when they are identified.

Those patients with long term conditions and those helping them to manage their condition will be aware of the important role of mental wellbeing. A physical health condition, especially a long term condition, can lead to depression and anxiety. These, in turn impair an individual’s capacity to self manage their long term condition. Anxiety can lead to attendance at Emergency Departments (e.g. for chest pains or breathing difficulties). By supporting patients and giving them greater self-confidence we can help to avoid stressful ED attendances.

Some issues are particularly relevant to older people. For example, access to psychological therapies in primary care is an important priority for us.

We know that across the country there is widespread experience of common mental health problems. These problems may or may not be recognised. They may become manifest in what might otherwise be avoidable attendance at GP surgeries.

There are complex interactions with levels of physical activity, eating habits, ability to work effectively or to interact socially, all of which can be associated with physical ill-health. Better provision of psychological therapies in primary care therefore remains a key national and local objective.

Clinical processes

Clinical governance

In redesigning services and patient journeys, care must be taken to ensure that clinical standards and outcomes are not compromised. Emphasis is placed on providing high quality clinical care across all LLR care settings and ensuring that patients are satisfied with the care they receive.

In order to ensure the clinical effectiveness of services delivered, we need to establish appropriate governance arrangements and ensure that adequate resources are in place to support these governance arrangements on a sustainable basis.

We will link clinical governance with existing performance management arrangements so that these arrangements are not merely a ‘paper exercise’ but actively contribute to the ongoing improvement of service delivery and patient experience.

Infection control

Cleanliness is an issue that the general public feel strongly about. Patients and the public consistently rate a clean hospital in the top five things they wish to see in a modern NHS. It emerged as an important issue for our public during our engagement events. Most participants felt that cleanliness is not given high enough priority in the NHS and should be the number one priority for the service. At regional engagement events, this subject was clearly one of the most important matters for patients and the public. In September, 50% of those asked said that providing clean facilities needs “a lot


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of improving”. 72% said that it was important for the NHS to provide information on infection rates in order to help people make choices about which hospitals to go to. At the event in January, it was overwhelmingly the single most important subject for patients and the public.

The “Darzi challenge” to health services is to ensure clean safe care by reducing infections and saving lives. This will need us to:

Raise public awareness in the East Midlands through a comprehensive communication programme.

Make infection control a Board level responsibility, receiving the same amount of attention at Board and senior management level as financial balance.

Ensure that all clinical guidelines are evidence based and common to all organisations so that patients get the best care and staff moving between organisations find it easy to transfer.

Screen all patients within three years, including screening for planned cases by the end of March 2009 and screening emergency admissions as soon as practicable within three years.

Publish validated information on MRSA and CDifficile rates at individual hospitals to enable patients to use this information when they choose hospitals.

As a first step towards better cleanliness, carry out a deep cleaning programme in all hospitals during 2008 and develop a sustainable evidence-based cleaning policy and procedures in all organisations.

Comply with the statutory obligation to ensure that all staff are educated in the prevention of Hospital Acquired Infections by developing and implementing rigorous education and training programmes.

Increase the number of matrons to 5,000 nationally by May 2008 to provide clinical leadership, ensure a clean environment for care and best practice infection control and improve clinical care standards.

Make cleaners a part of the healthcare team and ensure these staff comply with national standards, feel valued and receive the level of training and support they need to do their job.

Make sure all future buildings “design out” infection through reducing potential reservoirs for infection and ensuring adequate space between beds.

Make this a commissioning concern with joint investigations of problems and joint action plans and the use of financial sanctions if necessary.

The LLR health economy has worked hard to tackle infection control issues, achieving positive results in recent years. Local benchmarked performance demonstrates the following reductions in hospital acquired infections:

MRSA has decreased from a rate of occurrence of 1.53 in 2005/06 to 0.63 in


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period from April to September 2007.

C diff has also decreased, particularly in 2007/08 where occurrences have reduced significantly from 403 cases in Quarter 1 to 199 in Quarter 4.

To take these initiatives further and generate additional reductions, the LLR health economy is developing a single health community strategy for infection prevention and control. The strategy will be developed, and overseen by the Boards of the LCPCT, LCRPCT, LPT and UHL who will work together to deliver sustained improvement over the next three years. The aim of this strategy is to deliver a co-ordinated and effective approach to reduce the burden40 of infection in LLR.

Rehabilitation

Ensuring that we provide sufficient access to high quality rehabilitation facilities across LLR is a major concern for our health economy. We know that patients do not want to stay in an acute hospital setting any longer than they need to for clinical reasons. Changing the way we currently organise rehabilitation is a major priority for our health economy. We want to transfer as much rehabilitation as possible much closer to people’s homes and communities. This will mean enabling patients to transfer to appropriate facilities in local community hospitals after an acute episode of care. In many instances we want people to be able to rehabilitate in their own homes, particularly where this is possible after planned surgery. We know (from the Cochrane review) that early supported discharge and home based rehabilitation is effective. Significantly, recovery at home is also what most patients prefer.

Availability of and access to diagnostics

The issues of access to, and availability of, diagnostics was raised in each CTG. Slow access to diagnostics is a major barrier to improving care, speeding up diagnosis and reducing waiting times. Work needs to focus on three areas in particular: pathology, radiology; and physiological measurement. We need to be able to make a diagnosis quickly and give patients certainty about their diagnosis and management plan as early in their pathway as possible. CTGs put forward a number of ways in which this could happen including:

Expanding the number of clinicians and NHS professionals able to request tests and investigations.

Providing diagnostic tests and investigations, for example ultrasound, more locally in GP practices and pharmacies, community testing facilities, and community hospitals thereby improving access to them.

Reporting results more speedily.

40 Burden is defined as:

The rate/number of infections.

Multi-resistant forms of infection.

Avoidability.


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Centralising specialist diagnostics and the equipment and workforce needed to support these into specialist units and ensuring 24/7 availability where appropriate.

Considering the access requirements when planning new diagnostics and screening services e.g. CVD screening from 2009/10.

This will need to happen within a clinical governance structure that makes it clear who can request tests, who will report on tests, how they will do so, and who will act upon the report. Standards will need to be specified at each level.

Critical Mass

There is a growing body of evidence that hospitals providing high volumes of complex care have best outcomes. For example we know there is a positive relationship between volumes of specialist surgery and three key outcome indicators: mortality rates; reduced lengths of stay; and complication rates.

For the most complex treatment, the safest care is centralised care. This is the primary reason why specialist care should be concentrated in specialist centres. Secondary factors behind specialisation are changes to working practices including the European Working Times Directive (EWTD) and the increase of sub-specialisation amongst clinicians.

To support centralisation of care for the most seriously ill we will need to:

Re-examine the current configuration of some of our specialist services – in particular our stroke and heart attack services.

Commission care across LLR, and in some cases across the region, on a clinical network basis.

Ensure we support our ambulances by agreeing bypass protocols and investing in critical care transport and in the capability of ambulance staff to make correct diagnoses.

Workforce training and development

The models of care that underpin our vision are set out in the individual CTG reports summarised in Appendix 2 of this report. They will need us to develop new roles and new skills. Workforce development and training are fundamental if we are to deliver our vision and ensure we have the right staff in the right place at the right time. Our CTGs have identified a need for:

An increase in multi-professional and multi-agency education, particularly in relation to healthy living, prevention and end of life care issues.

Skill sharing across primary, community and secondary care and a joined up approach to training.

A structured programme to develop our clinicians to become clinical leaders.


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A workforce, education and training strategy that supports the regional vision and aligns recruitment and training with changing needs.

To support workforce training and development we will continue to link in with the University of Leicester through the Medical School to develop formal and informal training programmes. We will also create an environment which sets aside time devoted to training and supports this by providing funding and cover for clinicians whilst they attend training and development sessions. As services are provided closer to home in primary care and community settings, GPs and other primary care and community clinicians (nurses, pharmacists, optometrists, dentists) will be expected to offer more specialised services. We will need to focus on skilling up these clinicians to ensure that they are able to fulfil new roles.

Research and ethics

As a major teaching hospital, University Hospitals of Leicester NHS Trust is recognised as a centre for Research and Development. The LLR vision anticipates that all healthcare workers have a role to play in improving services through ongoing research and audit. Research and development as a key element of clinical work needs to be factored into job descriptions and plans and financial resources need to be made available to support this.

Ethical considerations are important in both service provision and research and the role of the Ethical Committee is to ensure that this remains a top priority. The role and remit of this committee will continue to be revisited as part of service and patient journey development. However, the role of ethics must be seen as wider than just the Ethical Committee and must be encapsulated within the organisation.

Commissioners will need an ethical framework to:

Provide a coherent structure for discussion, ensuring all important aspects of each issue are considered.

Promote fairness and consistency in decision making.

Ensure decisions are cognisant of appropriate evidence of clinical and cost effectiveness, costs of treatment, the individual need for healthcare, the needs of the community and national standards.


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Infrastructure and support

Choice

The choices that patients make about their healthcare will increasingly drive change and improvement. The more information patients have about their possible choices, the more their choices will drive improvement. From 2008 there will be free choice in LLR as across the NHS. We know from IPSOS Mori polls that those who felt they had more choice over their care were more satisfied. In LLR we will need to develop the information our patients will need to support and enable them to make informed choices. Communicating information, particularly to our diverse population, many of whom do not speak or read English as their first language, will be a challenge we must address.

In theory the one choice people have always had in the NHS is over which GP they register with. However in reality patients in LLR have not had such flexibility because access to GP services, particularly in the city, has not been to the level we would want it to be. Improving access to GP services is one of the main thrusts of our vision. As more GP services are provided within different models of community provision, so this will drive change and improvement I primary and acute care settings.

Affordability – including Payment by Results

Table 6 : LLR Health economy – financial summary 2005/06 to 2007/08

UHL LPT LCPCT LCRPCT£000 £000 £000 £000

2005/06 556,656 127,986 371,611 649,262

2006/07 588,666 133,189 404,353 714,135

2007/08 613,457 134,165 444,922 773,500

2005/06 60 18 -4,716 -18,023

2006/07 61 7 136 -17,759

2007/08 60 0 2,200 0

2005/06 370,378 93,869 1,316 52,706

2006/07 393,662 100,360 -3,675 42,0692007/08 422,050 125,067 -1,516 105,900

Income/ Revenue

Resource Limit

Retained Surplus/Deficit

Net Assets

The affordability and management of costs has emerged as an important issue for our public throughout our engagement process. Our public are concerned that we ensure proposals are affordable and that, where new money is invested, there are clear plans to redesign services to ensure the health economy as a whole remains financially sustainable.

The way funding flows around the system is important in this regard. Funding flows need to be used to incentivise the best practice described in our CTG reports. In particular the CTGs have expressed concern that the PbR tariff is restrictive and, in some cases, creates perverse incentives within the system. For LLR’s health system to work efficiently and effectively we will need to ensure that:

Funding can easily be transferred to support activity shifts from acute settings into the community and closer to patients. This work needs to underpin our community hospitals strategy in particular.

Tariff can be unbundled to enable commissioners to buy unbundled services such


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as diagnostics in settings outside acute hospitals, for instance in community hospitals. This work is essential as we move care and services closer to home and make full use of our valuable NHS estate across LLR.

There is a greater degree of sophistication within the tariff to enable us to differentiate between routine and specialist care.

Leadership

Our review has reinforced the fact that the NHS will need high quality clinical leaders if we are to succeed in making changes on the scale we have outlined in our vision and make a real difference for staff, patients, and the public. We recognise that we will need a structured programme to develop skills for clinicians to become the next managers and leaders in the NHS. Some of this work will be enabled through the Our NHS Our Future Programme and the support of our Clinical Forum of CTG Clinical Leads.

Partnership working

We recognise that we cannot achieve the vision set out in this document in isolation. The mental and physical health of the population has very broad social, economic and environmental determinants as illustrated in Dahlgren and Whitehead (1991) model below.

Figure 28 : Dahlgren and Whitehead (1991) – The main determinants of health

As we have described in this report, we will need to work closely with our partners in the city and county councils, the voluntary and private sectors and higher education if we are going to make an impact at the level set out in our vision. For example we know that the voluntary sector can help us enormously in planning our services and could also help us deliver more care. For instance, the role of End of Life Service Providers (ELSPs) could


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be performed by voluntary sector organisations. Equally, the private sector will need to be a partner in taking our vision forward. They will be able to provide services important to several of the clinical areas reviewed by the CTGs.

Communication and IM & T

Communication and IM& T challenges were raised as an issue by each CTG and are a key driver for change across our health economy. Effective IM&T is essential to integrated and seamless care. In particular the CTGs have stressed the need to urgently develop:

Electronic letters and coding – the electronic production and transmission of clinical letters (such as referrals, discharge letters, outpatient letters and out-of-hours care information) is an essential first step in creating an electronic patient record and enabling organisations to work across boundaries and offer patients true continuity of care.

A shared single electronic patient record across health communities – to enable NHS organisations to deliver care within an integrated pathway without having to ask patients to repeat information.

Electronic communication – to enable consultants and GPs to communicate securely across organisations.

Mobile access to clinical systems – to enable access to clinical systems regardless of physical location and to view and enter patient clinical details.

Commissioning

Practice Based Commissioning (PBC) is, potentially, a powerful lever for driving change. We will need to develop PBC across LLR to support and enable it to be a true catalyst for system innovation and improvement.

In addition, many of the recommendations in our CTG reports can be achieved through taking forward Local Area Agreements described above. For example, the creation of improved pathways that integrate a range of services, in particular those needed by vulnerable groups41 could be achieved through joint commissioning with local authorities.

Finally, we believe that the NHS’ development of Word Class Commissioning will be an important enabler of strategic change. World Class Commissioning is aimed at delivering outstanding performance in the way we commission health and care services. Local development of a Word Class Commissioning approach and associated skills and competencies will have a direct impact on the health and well-being of our population. It will be a major component of our vision to ensure:

41 For example benefits advice, housing, services for children, social care and health care for

older people.


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Better health and well-being for all – by improving health outcomes so that people live longer and healthier lives and health inequalities are dramatically reduced.

Better care for all – by ensuring services are evidence based, and of the best quality and that people have choice and control over the services that they use.

Better value for all – through making investment decisions in an informed and considered way, ensuring that improvements are delivered within available resources and working with others to optimise effective care.

In short, to deliver excellence for all.

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