Supporting the NHS in Scarborough and Ryedale Wednesday 8 November 2017

Malton Rugby Club, Malton.

Good evening and welcome • Introduce staff from the CCG

Aim of tonight • To have a “frank, open and honest conversation” about the

financial challenges facing the local health economy and what this might mean for future healthcare provision in Scarborough and Ryedale

• To update you on the work we have done

• To present you with a number of options we are considering to help address our financial position – and gather your feedback

Our Challenges

• Changing health needs of communities

• Poor health outcomes for people living in deprived and geographically isolated areas

• Workforce pressures from an inability to recruit and retain staff

• More people needing health services

• Higher costs of care

• To manage the budget and live within the constraints

Our Challenges (2) • Last year we were unable to deliver a balanced

budget – we recorded a deficit of £1.6 million against a budget of £181 million

• Over the last six months we have been working with NHS England and NHS Improvement on plans to recover our financial position

• We have taken some action and are obliged to do more – doing nothing is not an acceptable option

The Story so far…..

a range of workstreams and projects have been established to support delivery

• Clinical thresholds and health optimisation:

Stop before your Op and Fit for your Op Campaign

Obesity – promote Tier 2 weight management

Atrial Fibrillation – pilot programme to identify patient who may be undiagnosed

Hypertension – delivering NHS Health Check Programme

Reducing smoking in pregnancy

Type 2 diabetes - improved access to education programme – increased capacity of a multi disciplinary foot team – on call podiatrist to offer emergency advice

What we have done so far

Multi speciality Community Provider – an integrated health and social care service that aims to work across health and social care boundaries to deliver a holistic service for patients

Community based services – CCG working to enable more traditional out-patients specialist services to be delivered in the community from GP practices – eg:Dermatology services, rheumatology

What we have done so far

• “Red line services” at Scarborough Hospital Accident and Emergency – acute medical model at Scarborough Hospital

Maternity – reconfigured mid-wife led unit and obstetric ward

Paediatrics – Royal College visit & recommendations

• One stop clinic for Breast and Urology Services

• Programme of international GP recruitment

• Generic Health and Social Care Worker qualification at Scarborough Campus of Coventry University

• Nurse training to return to Scarborough from February 2018 – first time in more than 20 years

What we have done so far

Sustainable Services

What Next? • We have some difficult decisions to make

• However, we are legally obliged to deliver a balanced budget

• Provide value for money

• We have developed some plans and want to share these and gain your views of what is important to you

Next stage of the evening • You’ve heard the background

• The financial challenges

• But there is more to do and we need your input

• Three 10 minute presentations from key leads, on areas of potential cost savings:

Travelling for a hospital appointment or operation?

Reducing the prescribing of “Over the counter medicines”

Lifestyle Choices – would imposing more Clinical Thresholds be acceptable?

• Opportunity for you to ask questions

• An interactive session using the voting pads to gather your feedback

Any Questions from

what you have heard so far?

TRAVELLING FOR A

HOSPITAL APPOINTMENT OR OPERATION?

Why services need to change

Workforce

Cost

Access Quality

Technology

Workforce

• NHS employs 1.7m people across the UK and is the biggest employer in the UK, ranking fifth in the world

• 1.2m of those employed are in England, but the distribution is not even:

• In London – 33 doctors per 10,000 people

• In East of England – 22 doctors per 10,000

Workforce “Shortages of doctors and

midwives putting lives at risk;

The Guardian Aug 2017

“Thousands of NHS nurses and doctors posts lie

vacant” BBC News Dec 2015

“400 GPs a month leaving.

April 16 - March 17, 5,159 GPs left

the NHS” (NHS Federation)

2013-15: 243 vacancies for consultants in ED; 221 vacancies for

paediatric consultants”

(Office for National Statistics Jan 2016)

“There is a national shortage

of stroke physicians” (Centre

for workforce intelligence 2011)

“Scarborough salaries lowest in

the country” (Social Market Foundation

Sept 17)

Cost

• Increasing demand

• Ageing populations

• New technology

• New techniques

• Salaries

• Expensive buildings

• Smaller hospitals are comparatively more costly than large hospitals

Quality • Standards and guidance in abundance

Royal Colleges/Professional bodies

Clinical networks and clinical senates

Trauma, cardiac, emergency care, stroke

CQC/NICE/Clinical Reviews

Clinical expertise and experience

Department of Health/Public Health England/NHSE

STPs

What does all of that mean for us?

• Workforce/Financial/Quality issues

“Coastal communities are lagging behind ……with some of the worst levels of economic and social deprivation in the UK”

(Social Market Foundation)

Service changes to-date

2014 – Breast clinic

2015 – Hyper-acute stroke

2016 – Urology

Breast service - patient views • Recent comments for patients accessing the service

from Scarborough and Ryedale area

“It would be more convenient if the service was in Scarborough, but I would have

travelled to London to receive

this fantastic service”

“It would have been easier for

me to go to Scarborough

Hospital, but I understand

why”

“The One Stop Clinic is great –

getting the results in one

day”

Stroke performance

• Access to dedicated stroke unit

• Time to be assessed by stroke consultant

• Improved scanning times

• Use of telemedicine to access specialist opinion

• Rapid access to a specialist nurse

• Improved performance in the percentage of patients eligible for thrombolysis

• More patients with access to a swallow screen within 4 hours

• Better after-care plans for rehabilitation / nutrition

What impact does changing the location of a service have on patients?

Patient impact - negative

• Loss of some local services

• Cost to patients and possibly NHS

• Increased travel (and time)

• For inpatient services, patients may be in hospital away from family and friends

Patient impact - positive

• Improved quality and safety

• Appropriate staff and expertise

• One stop approach

• Increased use of technology

• Knowledge that we are making the best use of public funding

Our proposals

• Dermatology – Malton

• Some out-patients may transfer to GP practices rather than patients visiting hospital

• Service/site review

Conclusion

I propose that where there is evidence that moving services maintains or improves quality; ensures appropriate staff; and improves outcomes for patients, we move services.

Even though this may mean that patients need to travel for more services.

Any Questions from

what you have heard so far?

Reducing the

prescribing

of

“Over-the-counter-

medicines”

• SRCCG spends more than £1 million every year on self care products

• For paracetamol alone, the CCG spends around £150,000 a year

• More than £300,000 a year for everyday painkillers like paracetamol, aspirin, ibuprofen and co-codamol

• Almost £50,000 for hayfever remedies

• For indigestion £75,000 a year

“ 1 million is equivalent to: “

1,058 days of care in an Intensive

Treatment Unit (ITU) for critically ill patients

1,764 days of treatment in a

Special Baby Care Unit for seriously

ill babies

5,389 outpatient appointments

with a Consultant

99,700 blood tests

20,000 GP

appointments

20 community

nurses

ln addition

• Many over-the-counter remedies can be bought relatively cheaply and conveniently from chemists or supermarkets (four times less than it costs the NHS)

• Reduce consultation and GP time for minor self-limiting conditions

• Reduce waste – only buy what they really need

Future plans • Change behaviour/culture around the requesting of

medications on prescription

• Increase patient independence as they are encouraged and empowered to take care of their own health

• Encourage patients to self care rather than request these items on prescription

Patient impact - negative

• Some patients who receive free prescriptions may be required to pay for self care medicines

• Likely to have a greater impact on those on a low income and vulnerable groups

• Temptation to self prescribe and diagnose for anything and everything

• Take medicines that interfere with other medications

Patient impact - positive

• Increase patient independence as they are encouraged and empowered to take care of their own health

• Patients receive more information and control over their lives

• Utilisation of allied healthcare professionals

• More availability of GP appointments

• More GP time for patients

In conclusion

I propose that we stop prescribing some medicines that can be bought over the counter and save the local NHS £284,570 a year

Any Questions from

what you have heard so far?

Dr Billingsley/ Mark Lagowski, Service Improvement Manager

Clinical Thresholds – what are they? • Restrictions to treatment for some categories of patients -

taking into consideration treatments already tried and associated health factors

• Certain requirements will need to be met before the patient is referred for treatments

• Thresholds aim to balance impact of the condition, effect on quality of life, cost of intervention, effectiveness of intervention

• Procedure will not be funded unless the patient meets the threshold referral criteria or the exceptions policy

Clinical Thresholds – what aren’t they?

• They do not change how you access

– emergency treatment (A&E)

– Cancer and other ‘urgent’ treatment

• They do not impact on patients’ access to primary care, or necessary tests

Clinical Thresholds –– what do we currently do?

• Set thresholds detailing which procedures and/or interventions will not routinely be carried out

• Require certain tests or investigations, with required outcomes, before certain treatments are initiated

Current examples

Body Mass Index (BMI)

• Period of Health Optimisation required for six months for hip or knee surgery if BMI is 30 or greater

• Period of Health Optimisation required for six months for all other elective surgery if BMI is 35 or greater

Smoking

• Period of Health Optimisation for six months for all referrals to surgical specialties if patient is a smoker. Patients can however have their referral made if successful quit is confirmed.

Savings so far

• BMI and Smoking thresholds saved the CCG approximately £350,000 so far

So what more could we do? • Extend the period of Health Optimisation to 12 months

for smokers and patients with a high BMI (Vale of York CCG already does this)

• Insist on a mandatory amount of weight loss (Other CCGs including Vale of York and Hertfordshire already do this)

• Lower the threshold for all elective procedures to BMI of 30+

• Prevent access to surgery completely if patients do not give up smoking

What the public have already told us…… • Charging for drug or alcoholic related A&E

attendances

• Charging people for not attending GP appointments

• Charging patients for not attending outpatient appointments

Patient impact - negative

• Longer waiting time for treatment

• Potential for worsening of condition

• Patient may require access to other services ie: physiotherapy/pain management

• More impact on GP – repeat visits and potential increase in prescriptions

Patient impact - positive

• Improved Health and Wellbeing

• Lowers risk of potential surgical complications

• Faster recovery times from surgery

• Reduces other potential health issues caused by Smoking or Obesity

In conclusion

It is proposed that NHS Scarborough and Ryedale CCG look to impose further clinical thresholds to assist in achieving financial balance and protecting the future financial position.

Any Questions from

what you have heard so far?

You’ve heard the

arguments!

Now we’d like your views

Your views are crucial – get involved

• The buttons on the keypad correspond to the answers on the screen (for example A, B, C, D)

• Use the buttons on the keypad to select your answer

• You can only answer once so make sure you press the right button!

Tester Question – “How many sleeps until Christmas Day?” A. 37 days

B. 40 days

C. 47 days

D. 50 days

37 days

40 days

47 days

50 days

20%17%

57%

6%

From what I have heard this evening I now have a clearer understanding of the financial challenges faced by SRCCG A. Agree

B. Disagree

C. Don’t know

Agree

Disagre

e

Don’t kn

ow

79%

8%13%

From what I have heard this evening I believe the SRCCG will make the necessary decisions to achieve financial balance?

A. Agree

B. Disagree

C. Don’t know

Agree

Disagre

e

Don’t kn

ow

41%46%

14%

Would you be prepared to travel further for a hospital appointment? A. Yes

B. No

C. Don’t know

YesNo

Don’t kn

ow

73%

5%

22%

A service that was based in Scarborough is now being provided in York. Patient transport is arranged, but who should pay? A. The CCG by reducing

other services

B. Local authority

C. The patient themselves

The CCG b

y reducin

g oth

e...

Loca

l auth

ority

The patie

nt them

selve

s

16%

52%

32%

Would you like to see more out-patient appointments at your GP practice rather than having to visit the hospital?

A. Yes

B. No

C. Don’t know

YesNo

Don’t kn

ow

69%

14%17%

Would you support the CCG to move services, where there is evidence that maintains or improves quality and improves outcomes for patients, but may result in increased travel for some services?” A. Yes

B. No

C. Don’t know

YesNo

Don’t kn

ow

72%

22%

6%

Would you support the CCG to reduce the prescribing of some medicines that can be bought over the counter? A. Yes

B. No

C. Don’t know

YesNo

Don’t kn

ow

81%

11%8%

Would you accept more clinical thresholds, which could delay non urgent treatment for some patients? A. Yes

B. No

C. Don’t know

YesNo

Don’t kn

ow

66%

11%

23%

What is most important to you?

A. Access to services locally

B. The quality of care you receive

C. Shorter waiting times

Access

to se

rvice

s loca

lly

The qualit

y of c

are y

ou r...

Shorter w

aiting ti

mes

11%3%

86%

On the basis of the information you have heard tonight, please rank the three areas of potential cost savings in order of priority (with 1 being your most preferred way for the CCG to make savings and 4 being the least preferred option for savings). A. Extended travel

B. Reducing prescribing

C. Imposing clinical thresholds

D. Do all the above

Extended tr

avel

Reducing p

resc

ribin

g

Imposin

g clin

ical t

hresh

olds

Do all th

e above

23%19%

28%30%

Summary and Close

Thank you for your Feedback

Thank you for attending

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