news focus

Published: 31/10/2002, Volume II2, No. 5829 Page 10 12 13

Breaking up hospital services for over-arching strategic ends is a sure-fire way to make enemies.The government has learnt that the hard way and the 'Kidderminster effect'has resulted in efforts to take the heat - and apparently the politics - out of reconfiguration.Any day now, the Department of Health is expected to publish its framework on configuring hospital services.But the government has more than one policy on its books, and the repercussions of the European working-time directive - with its inevitable push towards centralised services - are being sharply felt across the UK.Here, HSJ examines the work in progress on future models of healthcare delivery, and the tensions between community-based approaches and the pressures to centralise care. Below, Tash Shifrin reports on 'After Kidderminster'.Overleaf, Ann McGauran looks at the impact of the working-time directive

They say that whoever you vote for, the government always wins. But if you fancy a party, you might try Wyre Forest, where voters will be able to celebrate something of a triumph with the imminent release of the Department of Health's framework document on reconfiguring hospitals.

The general election upset in Wyre Forest - where Kidderminster Hospital Health Concern candidate Richard Taylor swept home with a landslide - hit hard.Voters, angry at the downgrading of their local district general hospital, unseated Labour minister David Lock and elected Dr Taylor - an unprecedented success for a hospital campaign.

The government does not want another Kidderminster. Ever. The new framework, with its emphasis on 'services designed with local populations, not for them', signals a sea change in attitude.

NHS managers might also be pleased that at last there will be a clear framework for reconfiguring services after years of this being the focal point for public anger.

The government has been so sensitive on the subject that the independent reconfiguration panel promised in the NHS plan to consider controversial service changes has consisted of only a chair for the past 14 months and has yet to start work.

The DoH was staying tightlipped about the framework last week, but a draft of the document seen by HSJ shows the Kidderminster effect: Reconfiguration has 'become synonymous for many local communities with the loss of services, especially highly valued 24-hour emergency services, through closure and centralisation'.

The document also seeks solutions for health communities rather than individual hospitals and, crucially, it seeks to use service improvement strategies.

The paper aims to find sustainable solutions for local hospitals in the face of safety concerns and the impact of the European workingtime directive on staffing, both of which have exacerbated the trend towards centralisation.

In a key statement, it says the aim is to 'change the focus of reconfiguration from the location of services to the design and organisation of services'.

The draft paper examines examples of different hospital configurations.One is the solution devised for Bishop Auckland Hospital by Professor Ara Darzi in his review of acute services in Darlington and Durham, using a network across three hospitals. The emergency care and diagnostic centre at Central Middlesex Hospital and the urgent assessment, diagnostic and treatment hospital being piloted in West Cornwall (see box) are also cited.

An alarm was sounded in June by the Royal College of Physicians in a report on 'isolated medical services'. This identified 61 isolated services defined as hospitals admitting acute medical patients but without 24-hour cover for one or more of a number of key categories: acute general surgery, an accident and emergency department taking unselected admissions, resident anaesthetic cover, an intensive care unit or a cardiac care unit.

The college found that 54 per cent of the isolated services reported clinical risk issues due to lack of critical care facilities or anaesthetic cover.

College president Professor Carol Black says she was surprised to find that acute surgical cover was not the crucial ingredient for sustaining acute medicine, although 'it would be nicer if it was there'.

She says: 'I thought it would be number one. But in fact [the findings were] that acutely ill patients should not be admitted to hospital without critical care and appropriate diagnostic services.'

Royal College of Surgeons president Sir Peter Morris urges 'a reallocation of hospital services' if safe, high-quality services are to be provided in future.

Splitting emergency from elective work is one of the 'keys', he says, although the question of whether an 'elective hospital' can safely admit acute medical emergencies without surgical cover during the night is still to be resolved.

Wyre Forest MP Dr Taylor was not consulted by the DoH over its reconfiguration document, despite his unique popular mandate on the subject. He describes the Royal College of Physicians report as 'political dynamite'.

Dr Taylor is very interested in the west Cornwall pilot, which is based on work by strategic consultant Andy Black of Durrow on local medical emergency units, with a single team of staff covering the 'main' district general hospital and the 'satellite' unit. The west Cornwall scheme could preserve a small local hospital in the geographically remote town of Penzance.

Mr Black is reluctant to summarise a complex idea, but does say: 'In future it may be possible to remotely assess someone at 100 per cent the same clinical effectiveness as is done now in a district general hospital. If this is the case, it reopens the debate about how hospital services should be organised. The issue is when does it become 100 per cent equivalent.'

He adds: 'If you analyse what therapeutic actions are taken that impact on a patient, you can reanalyse which are place-dependent.'

Work by the NHS Confederation's Future Healthcare Network is also acknowledged in the DoH draft.

More than 25 acute trusts involved in development work - some in major PFI schemes - are involved in seeking to 'improve the content of what we build', says project manager Sylvia Wyatt.

The idea is to feed in the experience of those further down the development or building process to those nearer the beginning.

The network has focused on integrating planning around service design, taking in IT and workforce developments and then feeding that into building design.

Ms Wyatt says: 'Specialty-based planning is no longer sustainable or sensible. What's come out is work needing to be focused around care pathways.What works is the aggregating of specialties.' This means integrating medical and surgical work so that everything connected with, say, gut-related illnesses is brought together.

'These ideas are in development, ' Ms Wyatt says, stressing that the aim is not to be prescriptive. 'We are getting towards some principles for building, for example: You want local emergency care wherever possible.'

There is a general consensus that new configurations need to be tested and evaluated to make sure our hospitals are fit for the future. Everyone - the NHS, policy makers, hospital campaigners - will be keeping an eye on the results. l West is best? Partnership approach in Penzance The west Cornwall pilot scheme, funded with£245,000 from the Department of Health, could mark a ground-breaking partnership between the NHS and the local community as well as a pioneering reconfiguration.

Anthony Farnsworth, director of strategic partnerships at South West Peninsular strategic health authority, says the SHA is working 'in equal partnership with the campaign team'.This is the hospital campaign that brought together the local Health Watch group, Penwith district council, west of Cornwall mayors and others to put a 20,000-strong march on the streets of Penzance in April in a demonstration to rival those in Kidderminster.'Because of that, the local health community realised people really care, ' says campaigner Sheena Cox.

Now Mr Farnsworth says a 'consensus has begun to emerge' that Andy Black's model offers a way forward for the future of the West Cornwall Hospital in Penzance.'The local population is very concerned about preserving access to services and keen to explore what can be achieved in terms of retaining emergency assessment and treatment in Penzance, 'he says, pointing out that the district general hospital in Truro is 25 miles away.

'The idea is for as many patients as possible to have access to the quality of assessment and diagnosis in the remote site as at the DGH through telemedicine, other technologies and new ways of working between primary and secondary care.The pilot will be the major influence over the shape of future services at the hospital.'

Ms Cox says the two sides are working together to preserve what can be preserved.'Whether We are fighting for the same preservation is yet to be seen but we are sitting at the same table, ' she says.

Minute sta akes It is said by some to be the issue making the entire government tremble. Do the new European rules poised to limit the working hours of junior doctors stand any chance of being met - and will full compliance mean some trust closures?

Politicians are wondering if the European working-time directive for doctors in training will force their local hospitals to shut - potentially triggering a wave of Kidderminster-style victories for independent MPs. At least that is the 'Euro meltdown' scenario outlined by the British Medical Association's junior doctors committee. 'The government is terrified of the directive and terrified about service reconfiguration, ' according to committee chair Paul Thorpe. 'But It is far better to be 45 minutes from a hospital That is going to treat you properly than five minutes from an understaffed district general hospital.'

Compliance with the directive entails stepped reductions in juniors' hours. By August 2004 they will work a maximum 58-hour week, with all rest periods applying. That would mean 11 hours' continuous rest entitlement in 24 hours, plus 24 continuous hours' rest a week. Variations on the rest periods can be agreed, but would have to be replaced by compensatory rest provisions. Unless deferred, a maximum 48-hour week will apply by August 2009.

Is the committee just scare-mongering? Dr Thorpe says it has been trying - so far unsuccessfully - to negotiate an opt-out with the Department of Health that he claims would allow non-resident rotas to continue. He claims the alternative of putting everyone on to standard eight or 13-hour shifts to replace long resident on-call rotas 'might be the death of small district general hospitals'.

So is the government really committed to implementing the legislation for juniors? Progress so far has been patchy. In 1991 the nonstatutory New Deal was introduced to bring hours down to a maximum average of 56 a week.

According to the recent Audit Commission report Medical Staffing, only 2 per cent of acute trusts have all their training posts compliant with the New Deal. The DoH's own latest monitoring figures for all trusts in England say that 68 per cent of all junior doctors are New Deal-compliant.

NHS Confederation policy manager for human resources Alastair Henderson says: 'The directive is a challenge - There is no denying that.' But he argues that 'the rather more alarmist doomsday scenarios that we are going to close half the hospitals are wide of the mark. That would be unacceptable, full stop. That is not going to happen.'

This is not a simplistic issue about junior doctors and their rotas, he believes. He sees the driver for change as the need for service improvement - not just a requirement to comply with the directive.

'There are a whole range of things organisations are going to have to examine. That could include cover across specialties, use of night teams, working across health systems and looking at how and where services are provided.'

Would the new NHS consultant contract - with its extension of the working week to include evenings and weekend mornings - go a long way towards picking up the hours dropped by doctors in training?

'As consultant numbers increase and as we try to move to a more consultant-based service this is not going to replace juniors with consultants. But there will be more occasions when you will have a consultant on call or providing services and that will then help you in terms of junior doctors.'

But the likelihood of a no-vote from the ballott, which closed last friday, means the contract is offering little cheer at the moment.

Hugh Phillips is chair of the Royal College of Surgeons of England's working party on the directive. He believes the government is 'not prepared to break the law', and that the directive can be dealt with by changing the ways doctors work. 'In the future, one option is to increase the activity of consultants. At Oxford Radcliffe Hospital trust, trauma consultants live in at night, but it compromises day cover.'

He advocates increasing the number of specialist registrars and believes cross-cover - trainees covering late night duties for each other - can work for senior house officers 'in nearly all cases'.

He also wants to see much more use of non-medically qualified practitioners such as surgeons' assistants. 'Night cover could be developed and strengthened by the use of trained nonmedically qualified personnel working to protocols.'

Surgeons believe that emergency care will have to be networked and integrated across trusts, he says, 'because from 2004 we will not be able to recruit large numbers of junior staff to work the rotas'.

Bigger hospitals start off with larger numbers of specialist registrars and surgeons and will be more able to cope with the reduction in hours, he points out.

He mentions an integrated ambulance service for the severely injured that takes patients to the hospital best suited to them rather than the nearest Rupa Chilvers, project leader for Improving Working Lives for junior doctors at the DoH's South West action team, says: 'There are not the junior doctors to go round.' In some places extra doctors are the answer to achieving working-time directive compliance, she believes, but in others seven or eight more doctors 'feels like a waste of resources'.

The key is having a vision for the future, stresses a surgical directorate manager. 'Look at what is going to be required in five to 10 years' time - and in a short-term political regime That is difficult.

But it always pays off.'

Playing it straight: an end to zig-zagging At Royal Bournemouth and Christchurch Hospitals trust, the system of patient allocation and distribution was the problem leading to much of the New Deal non-compliance.Medical specialty teams had patients spread over too many wards and into some outlying surgical wards.

Junior doctors spent too much time zig-zagging the hospital to hunt for and treat patients. In June 2001 a ward-based consultant system was implemented, with each specialty allocated specific dedicated medical and non-medical wards.All medical patients on these wards were then automatically under the care of that specialist team.

Three months later, house officers and senior house officers were compliant, and specialist registrars were compliant in every aspect apart from achieving five hours'uninterrupted rest at night on 75 per cent of occasions.

Kirsty William, deputy general manager and strategic planner in the medical directorate, says: 'We have a consolidated multidisciplinary team working together.From the New Deal point of view it has been very successful in helping doctors to manage their day-to-day workload within normal working hours.

The directorate also trains B-grade healthcare assistants to do the routine things that nurses can do, such as assist the on-call medical doctors out of hours, taking blood and doing electrocardiograms.'Ultimately we can foresee that these roles will need to develop further.'

But Mrs William believes difficulties still lie ahead.'I think that potentially, due to our specific circumstances and the level of intensity that our junior doctors work at, full shifts will ultimately become inevitable to achieve the directive.

'However, we have to bear in mind the implications that this will have as you start putting registrars on night shifts out of hours that will have a significant impact on junior doctors' education.Also, putting doctors on shorter shifts spreads the numbers of doctors on duty at any one time who are here during the day more and more thinly.'

Finding out what else works By 2008 the NHS is expected to have net increases over 2001 of 15,000 consultants and GPs.

But despite this hoped-for growth, the DoH tells HSJ that the 20 pilots around workingtime compliance - recently selected to be tested in trusts - look at ways of implementation 'without necessarily needing to recruit more doctors'.

The DoH spokesperson adds: 'Funding is provided for genuine development and the proposals should be self-sustaining after the end of the pilot project.The pilots are looking at new roles and ways of working for existing staff to see how services can best be delivered.'