OUTLINE NOTES ON DISCUSSIONS
Present approximately 76 persons attended excluding speakers.
Sandy Macara spoke about the background to the meeting and introduced Hugh Ross and Kevin Woods with brief biographies of both speakers and their current posts.
Hugh Ross
(as his script video & CD)
The outline plan Building better health services for Bristol, North Somerset & South Glos was the culmination of 2 years planning and consultation with the public, councillors & MPs. Hugh Ross presented a map of the current situation (dated 17 July2002)
The site for the new hospital in South Bristol is about to be decided. Cossham Hospital is considered as not fit for purpose and is not easy to adapt, the public are being consulted. Yate is a new population centre and must be catered for in the S. Glos planning. Bristol North PCT are debating this in conjunction with a special needs assessment. Plans are being developed for Keynsham.
Some options being considered:
Closure of Frenchay or Southmead or a rebuild on a green field site. There would be one A and E Dept instead the present two in north Bristol. One of the sites may include a community hospital.
Service changes being discussed with the probable closure of the BGH. Many of the services will be provided at the new South Bristol hospital.
Enhancement of Clevedon Hospital.
Bringing together all the children's services and inpatients to go to an expanded BCH.
Cardiac services are considered excellent but the accommodation is very poor and needs to be replaced.
Replace BRI Old Building with a new facility
Reorganise Frenchay & Southmead by bringing together specialist services and emergency services the view is that the service cannot continue to provide 3 separate emergency units.
The loss of the Kidderminster parliamentary seat at the last general election caused a concentration of minds amongst politicians! It is essential to ensure that the public are fully consulted at every stage of the planning process.
Comments regarding the plan are most welcome.
The website bhsp@bris.hsp.nhs.ukhas achieved almost 4000 hits.
Kevin Woods Implementation, how, when and by whom?
The SHA has various important actions to take in the very near future. These include presenting a strategic outline case (SOC) to the Dept of Health. The matter may be considered under 2 headings: process and criteria.
Process The initial document has to be presented to the DOH by April 23. It will then undergo a process of peer review and prioritisation. A provisional DOH view of the plan should be available by the end of July 2004.
The plan will involve a re-activation of a plan submitted by UBHT previously (no details given but will probably includes replacement of the old 1735 medical block).
So far no SOC has been received from NBHT. There is also a major proposal to reprovide cardiac inpatient services.
The timetable for implementation will be influenced by many factors including the need to avoid too many large building projects being undertaken nationally at the same time with the attendant risk of overstretching capacity.
Throughout the next few months there will be a process of extensive consultation.
Criteria Kevin Woods listed a number of criteria that must be satisfied. These include value for money, affordability, public support, clinical support, Health Service need (which is discussed below) and the extent to which the legacies of the past are likely to be remedied. The scheme must remain viable over the next 50years.
Health Service Need This term refers to specific NHS criteria against which any proposed plan will be judged. They include the following:
1. General strategy. This includes likely demographic and demand changes. Is the proposal likely to lead to desirable integration and will it reduce duplication?
2. Policy Imperatives. Does the plan embrace national priorities including the National Service Frameworks.
3. Location and waiting times
4. Improved clinical quality.
5. Training, teaching and research. Recruitment of staff. Accreditation
6. Quality of care, environment etc e.g. hygiene and safety standards.
7. Effective resource use
8. The need to get the correct balance between acute hospitals and primary care services.
Uncertainties These include money!, workforce requirements and national policy. The latter includes PbR (payment by results), plans for patient choice, and the emergence of new providers outside the NHS. Lastly, and importantly, there are events! A difficult path lies ahead but the best chance of progress lies in achieving public and clinical support for the changes.
Discussion of first two presentations
The chairman asked whether the DOH could cherry-pick, accepting some parts of the plan but not others. Mr. Woods replied that the best hope was that the plan as a whole would be supported by a coherent consensus within Bristol. There would be a number of interdependent elements. This would make cherry picking more difficult.
Dr. Southwood asked if the plan covered the expanding population of North Somerset. Hugh Ross replied that so far no plans had yet been put forward by the PCT. These are required.
Michael Whitfield asked what was going to happen to the financial deficit. Kevin Woods replied that the deficit will not be wiped out. It will be worked out! A high level of support from the rest of the NHS had been given £60million for this year and £40million next year. The DOH will require to know how Bristol is going to get rid of its deficit.
d) Sonia Mills (Chief Executive of North Bristol NHS Trust). The deficit must be eliminated by 2006. A major problem in the past had been the well known overspend on agency nurses. Cossham and Blackberry hospitals are very expensive to run and represent a further difficulty.
Will Warin, Chair Bristol North PCT: Primary Healthcare to the rescue
There has never been a systematic attempt to explore the work that could be done within primary care rather than in acute hospitals. 3 initial points should be made;
Healthcare should be looked at as a whole system. Hospitals should exist to support the GP. They should not be regarded as stand alone institutions.
The need for hospital care should be redefined.
The possibilities for developing care outside hospital should be explored.
What might healthcare in Bristol in 2015 look like?
1. There should be a reduction in the number of emergency medical admissions and we should aim for a 20% reduction in length of stay in hospital.
2. Chronic disease management. We should aim for a 40% reduction in hospital admissions for people with COAD. There was mention of the well-known Kaiser project about which much has been written in the BMJ.
3. We should practise anticipatory management targeting particularly those at risk (e.g. the EverCare Project).
4. GPs are the people skilled at managing risk outside hospital. Important elements include NHS Direct, GP Out of hours service, and a possibly expanded role for the ambulance service. At present 30% of admissions see a GP first.
5. Much improved intermediate care organized largely outside hospitals.
6. Various Secondary Care solutions outside acute hospitals were possible eg siting a Day Hospital (run by GPs) in the grounds of an acute hospital.
7. Outpatients. -Aim for a reduction of 50% in the number of hospital appointments.
8. Investigations. Many investigations can be done on a peripheral site and not all patients require to see a consultant.
Infrastructure and organization.
There should be two acute hospitals. However these should function as one with maximum collaboration/integration between them This would be facilitated by the creation of one acute trust. There is scope for an expanded role for community hospitals
Finally:
There has been too much clinging to the DGH in the past. We need a new vision. The future lies with clinical networks involving the maximum of collaboration between us. We should harness the ambitions, drive and enthusiasm of GPs and others who want to improve care outside hospital but at the same time identify the key role of hospitals in certain situations.
Discussion
Stephen Illingworth: (invited discussant)
This is a visionary approach. However, it will cost a lot of money. It is unclear whether the necessary resources will be available. It is also unclear whether the support of the troops can be assumed. Stephen Illingworth responded that at present GPs are shell shocked with a multitude of recent changes and also the implications of the new contract. He repeated his enthusiasm for the developments tha the had outlined.
Will Warin responded: Essential to invest now to build capacity later. Care in hospital is not the best option. Stephen Illingworth comment: if you have a shorter hospital stay thenyou need to create an intermediate care environment.
Derek Alderson How to get the best from specialist services integration across the City
Evolution of specialist services These changes have occurred over 20 years: They are still continuing and the situation is not static. Foetal Medicine is one of the latest specialities to be born. General surgery now hardly exists. Ever increasing specialisation is occurring. All this raises the question of how emergency cover is to be provided at a time when some surgeons can no longer undertake emergency abdominal surgery. One of the important implications. of all this, particularly the demise of generalism, is that integration is absolutely essential.
There also a number of important external factors including the requirements for appraisal, revalidation, clinical governance, audit, education and training. Newly appointed consultants often start off as junior members of large teams.
There is no doubt that increasing professional accountability is one of the factors encouraging specialization. The new Working Time Directive is having major effects on the situation. The new consultant contract is another element.
One result of increasing specialization is that difficult/complex cases are increasingly being referred from elsewhere to centres of the type which exist in Bristol. It is essential that allowance for this be made in the BHSP. Bristol hospitals must reckon to provide for more than the local population.
Political considerations
Some of the directives from the DoH are clinically unhelpful and sometimes contradictory. Targets, initiatives and priorities can conflict.
Some guidance documents from the DoH cause patient flow from outside the city into the city
Some patients receive hospital care for the wrong reasons.
What should be done?
Each speciality must provide a single service spanning the trusts and appropriate sites.
The integration of allied specialist services should dictate the number of hospital sites needed for each specialist group.
There must be one acute trust.
Clinicians must take the lead in developing specialist services. This is not a task that can be undertaken by non-clinical managers.
Discussion
Dr John Pounsford was to be involved at this stage but was unable to attend at the last moment. The chairman asked the meeting, on a show of hands, to express a view regarding one service on two sites. There was general agreement with the proposal.
Paul Dieppe Question and answer
Paul Dieppe introduced his Session by stating that we were here to ask questions and not hark back to the old agenda, but tolook at the new points raised tonight.
Gordon Stirrat asked Social Services have not been mentioned tonight, but are they being discussed?
Hugh Ross replied the interdependence of health andsocial services is recognised e.g. South Bristol Community Hospital will have social service input
Kevin Woods added at SHA level there is increasing discussion with social services but also there is a need to know how the PCTs see hospitals.
Tim Chambers: Those planning childrens services are ahead of the game! The new childrens service will be generalist based. It will be as close as possible to home. In-patient care will be on one site.. There be a special managerial structure for childrens services.
Beryl Corner outlined how in 1946 management of the childrens services had a comprehensive homecare service and a clear reporting link to the centre of the service.
Ivor Doney do we think we were wrong to close the Homeopathic and Ham Green Hospitals?
Kevin Woods replied there is an appetite for change in Bristol. We need to make some early moves.
Charles Ward asked about the psychiatric services
Hugh Ross replied The SHA is working closely with the mental health trust in developing new community bases and expanding existing community teams.
Sheila Willetts All specialist services must be run as a single entity..
Hugh Ross replied Both acute trusts and the PCTs have signed up to an acute services strategy. A single acute trust would not necessarily solve all the problems.
Stephen Illingworth asked whether a single service would be too inaccessible and in danger if being too centralist?
Derek Alderson replied surgical inpatient services are only a part of the service.
Gabriel Laszlo Some people think that secondary care is not very good in tertiary centres.
Will Warin replied Tertiary centres do provide excellent care for complex problems, Bristol will become a major regional centre.
John Harvey please comment on a 2 hospital model, 1teaching + 1 A & E
Paul Dieppe if there will be 2 hospitals, how will they work?
John Webb With the present differentiation, will brother love prevail?
Tim Southwood Why do planning authorities not point out inaccessible and unsuitable sites?
Kevin Woods replied The SHA will not stand in the way of proposals which will deliver better services. Is the clinical community up to making these changes?
Richard Langton Hewer The current situation is a shambles from a medical point of view. Bristol doctors are simply not organized. We have no mechanism for debating the issues or for formulating a considered medical view of the important matters being discussed today. Most of the present problems are not the direct responsibility of the SHA. They are a matter for Bristol. For instance, the city-wide integration of specialist services, which everyone considers to be essential, is a matter on which doctors in the city should take a lead and fast!
There being no further questions of the Chairman thanked all discussion leaders and contributors via questions and closed the meeting at 20.50 hours.
Janet Keen / Richard Langton-Hewer