Local hospitals in London summary - London Health Programmes

Local hospitalsin LondonRight treatment, right place, right time

The concept of a 'local hospital' is a key element of Healthcarefor London's plans for improved healthcare in the capital.The majority of care will be provided in five settings: home,polyclinics, local hospitals, major acute hospitals andspecialist hospitals.A local hospital is where most people will receive acute(hospital) treatment; whether it is a 3am visit to the A&Edepartment, the birth of a first child, or emergency surgeryon a fractured hip.A hospital close to home,providing high-quality careis critical to all LondonersAs the main providers of hospital care, ‘local hospitals’ willbe the vital link between specialist centres for the mostseriously ill and community-based care, such as GP surgeriesand polyclinics. As the NHS works to develop world-classhealth services across London, we want to ensure localhospitals provide the right treatment, in the right place,at the right time.In July 2007, after wide-rangingdiscussions with patients andNHS staff, Lord Darzi producedHealthcare for London:A Framework for Action.This report was a blueprint forimproving health services inthe capital and highlighted theneed to evolve NHS services.Key recommendations includedoffering increased specialist carefor the most seriously ill, and anemphasis on more communitybasedcare, such as theintroduction of polyclinics.The report proposed that while‘local hospitals’ should continueto provide the majority ofinpatient (hospital stay) carethey must evolve within thechanging NHS landscape.From these proposals theHealthcare for Londonprogramme, run on behalf ofthe 31 primary care trusts (PCTs)in London, has produced a reportshowing how a local hospitalcould operate in the context ofthese wider changes.The report tests the future localhospital model, with input andchallenge from clinical staff infour London hospital trusts.The report concludes that thefuture local hospital model offerssignificant advantages for thequality of care for localpopulations, including betterclinical outcomes (such assuccessful treatment and survivalrates) and improved patientsafety. With careful planning andimplementation the model is alsoshown to be financially viable.The report offers guidance forPCTs and hospital trusts on howto manage this transition andensure this is factored into theirlong-term strategic plans.This document is a summary ofthe key findings of the report.For the full report visitwww.healthcareforlondon.nhs.ukLocal hospitals in London2

A 1960s model in the21st centuryIn the 1960s, many Londonhospitals developed around thedistrict general hospital model,providing a similar range ofservices for very differentpopulations.However, in the past 50 yearsthe way we deliver hospitaltreatment has significantlychanged. Medical advances suchas angioplasty and statins for thetreatment of heart disease,thrombolysis (clot-busting drugs)for the treatment of stroke, andimaging such as MRI and CTscans have drastically changedhow we prevent, diagnose andtreat routine and serious illness.But the pattern of services haschanged very little in responseto these developments. Londonhospitals still largely function asstand-alone entities, often withlimited links to other parts ofthe health service, such asneighbouring and specialisthospitals, GPs and communityhealth facilities. As the NHS inLondon works to transformhealthcare services, the beliefthat locally-based hospitalscan be all things to all peoplemust be challenged if we areto improve efficiency andpatient outcomes.Healthcare for London iscurrently working to developspecialist centres for stroke andmajor trauma (seriously injured)patients. Strong clinical linksbetween these centres andneighbouring hospitals will playa vital role in a patient’s longtermrecovery. In addition tothis, polyclinics will provide morecommunity-based care andwill strengthen the relationshipbetween GPs and local hospitals.For more information on howand where patients will betreated see page 5.What will a future localhospital look like?In most respects, the future local hospital will look and feel similarto what is currently provided in a district general hospital. Changesshould take place where it is clear that the quality of services will beimproved. For example, the development of specialist services formajor trauma and stroke patients will save lives; while enhancingcommunity-based services for people with long-term conditions willprovide a more accessible, responsive and personalised service.Serving a local population of around 250,000, a local hospital willremain the main provider of hospital care for most Londoners.There will not be a ‘one-size-fits-all‘ version of the local hospital asthe range of clinical services should be driven by local needs.As a minimum the core services would include:• A&E department (24 hours)• Paediatric assessment unit(18 hours)• Urgent care centre (treatingminor illness and injury)• Emergency surgery fornon-complex cases(12 to 16 hours a daye.g. abscesses, internalbleeding, bowel obstruction)• Medical cases requiring ahospital stay (e.g. pneumonia,heart failure, liver disease)• Critical care facilities,level 3 (managing patientsthat require ventilation)• Outpatient services• Maternity services witha special care baby unit• Diagnostics (includingX-ray, ultrasound, CT scans)• Pathology (blood tests, etc)Local hospital core services3 Local hospitals in LondonLocal hospitals in London4

The right treatment, in the right place, at the right timeRebeccaage 42GenerallyunwellRebecca visits her local GP who diagnosesdiabetes. She is then referred immediately tothe polyclinic which is linked to her practice.GPRebecca is seen by a specialistdiabetic nurse and receivesfurther tests and ongoing care.Rashid is taken byambulance directlyto a major traumaunit and is seen bya team of specialists.No more than30 minutesSPECIALISTMAJOR TRAUMAUNITPatient benefitsBenefits• Rebecca receives ongoing care in one location.This includes retinal (eye) screening andinformation on managing diabetes, such asdietary advice.• She avoids unnecessary trips to hospital and hasbetter long-term management of her condition.Ultimately this leads to fewer medical complicationsas she gets older.Rashidage 23Multiple seriousinjuries froma motorbikeaccidentValerieage 51StomachpainsGPGPPOLYCLINIC(INCLUDESURGENTCARE)GPValerie visits A&Ewith stomach pains.She is diagnosed with acuteappendicitis and admitted.She is later operated on.GPGPA&E(URGENT CARE)Rashid is later moved tohis local hospital for recoveryand rehabilitation needs.MAJOR ACUTE HOSPITALOnce Ida has received heremergency care, she istransferred to her localhospital for ongoing careand rehabilitation.SPECIALISTSTROKE UNIT• Rashid is seen by an onsite team of skilledspecialists including a neurosurgeon,cardiothoracic surgeon and orthopaedic surgeon.• His survival rate increases by 25% because hehas access to expert care in one location. He alsomakes a faster recovery and is later moved to alocal hospital for rehabilitation.• Valerie is promptly diagnosed with appendicitis atthe urgent care centre, which is integrated with theA&E department. This ensures she is triaged asquickly as possible, avoiding a lengthy wait.• She is assessed in the surgical assessment unit andis operated on by a skilled surgical team that handlesemergency cases only, ensuring better clinical outcomes.Johnage 64Poor visionJohn visits his local optometristwho diagnoses glaucoma andrefers him to the optometryservice at his local polyclinic.LOCAL HOSPITAL• Early detection of John’s glaucoma and maculardegeneration reduces his chances of going blind.• At the polyclinic he gets advice on his housingneeds from council services also based onsite.• At the specialist hospital he is seen by one of theUK’s top ophthalmologists and has access togroundbreaking treatment.Tomage 11Suspectedbroken armHIGH STREETOPTOMETRISTTom visits his local polyclinic.He is seen without anappointment. He has anX-ray and his arm is putin plaster.POLYCLINIC(INCLUDESURGENTCARE)GPGPAt the polyclinic John is alsodiagnosed with maculardegeneration and is referredto a specialist eye hospital.GPA&ESPECIALIST HOSPITAL(EYE)• Tom avoids a lengthy wait in an A&E department.• He is seen by his local GP who is based at thelocal hospital and has access to X-ray andplaster facilities.• He is directly referred to the fracture clinic basedwithin the local hospital, at a time convenientto him.Idaage 72Suspectedstroke5 Local hospitals in LondonLOCAL HOSPITALIda travels by ambulance,bypassing her local hospitaland going straight to the majoracute hospital which hasa specialist stroke unit.No more than30 minutes• Ida receives an assessment by a specialist, CT scan andaccess to thrombolysis (clot-busting drugs) within30 minutes of arrival at hospital.• Thrombolysis treatment stops the impact of strokeand speeds up overall recovery.• Three days later Ida is moved to a local stroke unit andis seen by the dedicated stroke rehabilitation team.Local hospitals in London 6

How will this be different froma district general hospital?Better surgicalsafeguards foremergency surgeryEvidence shows that surgeryshould not be carried out at nightunless a patient’s life or limb isthreatened. Under theseproposals local hospitals willcarry out onsite emergencysurgery between 12 and 16hours a day, with emergencysurgery for life-threateningconditions outside these hoursprovided by a wider clinicalnetwork. This means a dedicatedemergency service could beprovided around the clockthrough a network of two or morehospitals, run by senior doctorswith a skilled level of expertise.This will ultimately improveclinical outcomes and save lives.Separating emergencyand elective surgeryTo further improve surgicaloutcomes, the report proposesthat elective (planned) surgeryis separated from emergencysurgery. This will benefit patientsas elective surgery is less likely to7 Local hospitals in Londonbe disrupted by the arrival ofemergency cases. And healthcareassociated infections could befurther prevented if patients areseparated and all elective casesare screened before admission.Getting the rightdiagnosis from asenior doctorIt should be a key objective of alocal hospital to ensure thatsenior doctors are available tosee patients at an early stage.Patients will benefit from moreappropriate treatment, plus itwill ultimately reduce patients’length of stay.Senior doctors should also bemore available during weekendsand out-of-hours, including anincreased consultant presence inA&E and the paediatricassessment unit.This improvement will besupported by increasedconsultant numbers over thecoming years. The workforcedevelopment strategy, producedby NHS London, will look closelyat what staff training anddevelopment is needed.Establishing clinical networksto underpin improvementsClinical networks will help ensureLondoners are seen by the rightperson, in the right place, at theright time and will be criticalto how local hospitals evolve.These networks will be developedbetween hospitals and partnerorganisations, such as a nearbySouth West London ElectiveOrthopaedic Centremajor acute hospital with aspecialist stroke or major traumaunit, as well as other clinicalspecialties such as emergencysurgery and paediatrics. Patientswill benefit from an expertopinion earlier in their diagnosisand treatment.This purpose-built specialist centre is located on the EpsomGeneral Hospital site and is run on behalf of four hospitaltrusts. Set up to alleviate pressure on hospital waiting listsfor hip, knee and shoulder replacement surgery, the centrereplaces over 4,000 joints a year. It has kept waiting listsdown, has had no reported MRSA infections and, lastyear, received no patient complaints. Patients are ableto go home sooner as there is a low average length ofstay for hip and knee replacements.Between them, the trusts operate a risk-sharing agreementwith clear guidelines and protocols for managing a safe,effective and high-quality service. As a result of the highvolume of operations, the centre has been able tonegotiate better deals with companies who manufacturethe replacement joints and is therefore cost-efficient.Local hospitals in London8

Introducing urgentcare centres andpolyclinicsFor the treatment of minorinjuries and illnesses, a localhospital could also include anurgent care centre, integratedwith the A&E department.Patients will receive a fasterdiagnosis and be transferred tothe most appropriate place ofcare, freeing-up A&E staff toconcentrate on the most seriouscases. An urgent care centrecould be based in a polyclinicwithin, or next to, a localhospital. The polyclinic will alsooffer GP appointments, withaccess to a wide range of healthand community services.Improved maternityand children’s servicesIt is intended that all localhospitals will include a paediatricassessment unit (PAU), staffed bysenior doctors who can quicklyassess children and minimisethe need to wait in A&Edepartments. The units willoperate as part of a widernetwork of paediatric services.This could include localhospitals linking together tooffer a paediatric inpatient wardon one site in addition to a PAU,or alternatively partnering witha nearby major acute (largehospital). A seriously ill childwho requires specialist care orcomplex surgery will be treatedat a specialist centre.Maternity services will alsobe retained in a local hospital.The service will be supportedby a special care baby unit(level one) and will managewomen who are not classifiedas high-risk. Both paediatricand maternity services are thefocus of more detailed workwithin the Healthcare forLondon programme.Dignity inend-of-life careThere is strong evidence toshow that hospitals do notalways manage end-of-life careas well as they could. More thanhalf of all complaints receivedby NHS trusts relate to patientswho have died. The complaintsare predominantly about poorcommunication, lack of basiccomfort, privacy andpsychological care.Managing financesChanges to how and wherepatients receive care will impacton where and how moneyis spent.Healthcare for London hasexamined the financial impactof implementing its 10-yearprogramme. It was concludedthat the overall effect of thechanges proposed in thestrategy could result in around a15% reduction in income for thelocal hospital over the next fiveyears. This reduction in incomecould be partially offset byincreased demand for services.However, these changes will bechallenging and will requirededication, resources andexcellent skills to achieve them.Work is underway as part of anational strategy on end-of-lifecare. While this highlights theneed to offer more support tothose who choose to die athome, it is clear that the manypeople who will still die inhospital deserve better care.There is an opportunity todevelop a more hospice-styleenvironment in local hospitals.There are opportunities fortrusts to broaden the range ofservices they offer to meet localneeds; and to develop servicesthat link closely with generalpractice and community services,as well as with specialist hospitals.Opportunities could include:• extending rehabilitation andintermediate care services• provision of an onsite polyclinic• developing local niche services• the movement of someelective surgery from majoracutes to local hospitals.9 Local hospitals in LondonLocal hospitals in London10

A safe, sustainable futureIn the proposed model, the local hospital has a strong future inLondon. Local hospitals have the potential not only to be clinicallyviable but to directly improve the quality of care patients receive.But these changes cannot be made in isolation. The NHS landscapein London will change over the next 10 years. This will include thedevelopment of specialist centres for the most seriously ill, and morecare delivered in the community. The capital’s hospitals must evolveto ensure all Londoners have access to world-class hospital services.To download A local hospital model for London or find out moreabout the Healthcare for London programme visit our website atwww.healthcareforlondon.nhs.uk“Local hospitals will continue to be wheremost Londoners receive their hospital care.They have the potential to offer highvolume,routine procedures to a goldstandard,ultimately improving clinicaloutcomes and reducing the amount oftime a patient needs to spend in hospital.”Celia Ingham-ClarkClinical lead, local hospitals project and medical director,The Whittington Hospital NHS Trustwww.healthcareforlondon.nhs.uk Published November 2008