Governing Body meeting public questions - 5 February 2019

These are the public questions and answers about Healthy Weston from our Governing Body meeting held on 5 February 2019.

How can there be direct admissions of patients onto hospital wards overnight by GP referral when there is no bed availability overnight (evidenced  by KHO3 report average daily number of available and occupied beds available  by sector)?

The latest KH03 publicly available data for July 2018 to September 2018 shows that the bed usage at Weston Hospital was running at 88.7% which is above the national average of 87.3%, although at times of high pressure the levels of bed occupancy at Weston does increase significantly. However, the number of beds available at any given time is the same regardless of whether admissions come directly from the community or via an A&E department.

High bed occupancy is driven by a variety of factors, including avoidable attendances and admissions and an extended length of stay once admitted. The new integrated frailty service is designed to address all of these issues for elderly patients, who occupy the great majority of Weston’s beds.  Based on evidence of a similar models that have been introduced elsewhere in the country, we estimate that around 3,000 attendances at hospital will no longer be required at Weston Hospital due to improved care to help people stay well at home.

What about the patients who will die during that 30 minute transfer to Bristol or Taunton?

The evidence has been clear for some time that patient outcomes are not driven by moderate increases in ambulance journey times, but by the service waiting at the other end to treat the condition. That is why, for example, some of the most severe and life threatening conditions such as major trauma (e.g. severe road traffic accidents) are centralised. There are only two major trauma units in the whole of the South West of England, located at Southmead and Plymouth.

The Healthy Weston programme has worked extensively with the ambulance service to understand the clinical risks associated with increased journey times.  We are also able to draw on the independent research that was published in July 2018 by a consortium of universities including Leeds, Sheffield and York.  This study looked at the population impact of the closure of five emergency departments between 2005 and 2011 and found:

There was no statistically reliable evidence that the reorganisation of emergency care was associated with an increase in population mortality. This suggests that any negative effects caused by increased journey time to the A&E can be offset by other factors; for example, if other new services are introduced and care becomes more effective than it used to be, or if the care received at the now-nearest hospital is more effective than that provided at the hospital where the A&E is closed.

What extra resources will be given to Bristol and Taunton to cope with the extra patients?

Hospitals are funded based on activity carried out so the receiving hospitals will be paid accordingly for the additional activity. Senior doctors and managers at the receiving hospitals have been involved in agreeing the clinical pathways that would support patients moving and have confirmed that they have the capacity to manage these levels of activity.

How would patients requiring surgery at night or more complex critical care be repatriated to Weston when operated on at neighbouring hospitals? 

Patients who live locally in and around Weston who receive emergency surgery and/ or extended level 3 critical care at larger local hospitals under these proposals would be repatriated back to Weston Hospital by ambulance for the remainder of their inpatient stay once doctors have agreed that they are well enough to transfer. Patients are already routinely transferred between hospitals every day for a variety of reasons and so the process to do this is well established.

Chemotherapy is already provided by Weston Hospital so what added value is there in the proposal?

Not all chemotherapy treatment is provided at Weston Hospital.  Our plans are to expand what is provided at Weston Hospital or in the community.

The letter states “under these proposals 97% of people who currently use services at Weston would continue to do so”. This appears be pure rhetoric, where is the evidence to support this?

The evidence to support this can be found in detail in the pre-consultation business case and associated appendices.  These figures are based on modelling that has been agreed with the Directors of Finance and Medical Directors from the neighbouring hospitals. 

Weston Hospital A&E department is presently commissioned as a 24 / 7 Type 1 emergency department. The safe staffing levels of emergency medicine doctors for the department presently has been established as 8 Consultants and 9 Middle Grade doctors. Under the Healthy Weston proposed model for Weston Hospital A&E department what are the proposed staffing levels of emergency medicine consultants and middle grade doctors?

The precise numbers of A&E specialists, GPs, nurses and other health professionals will be developed as a result of the further work done over the course of the consultation period and beyond. What is clear now, however, is that this proposal concentrates our resources at the times of day when local people need these services most (8 out of 10 people have historically accessed Weston’s A&E between 8am and 10pm), rather than diluting scarce staffing resources over the course of the full 24 hour period when local doctors think this need can be met in a more sustainable way.

The NHS categorises A&Es by ‘Type’ (1, 2, 3 and 4). Weston Hospital is presently categorised as a Type 1 A&E department. That is to say a consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients. Please can it be confirmed that the proposed model for Weston Hospital A&E would more closely resemble a Type 3 A&E. That is to say a doctor led community sited A&E that treats at least minor injuries and illnesses (sprains for example) and can be routinely accessed without an appointment?

We recognise that to find a solution to the challenges faced by the system in delivering the best possible urgent and emergency care we will have to develop new and innovative ways of delivering services. Therefore, the model being put forward does not neatly fit into any of the type 1-4 definitions, although with continued emergency doctor presence during the proposed opening hours, it is certainly able to treat far more complex and serious conditions than minor illness and injuries.

Of the 5 models of care proposed within the document, “Healthy Weston, joining up services for better care in the Weston area (3rd December 2018)” which does the proposed model within the Healthy Weston Pre-consultation Business Case - 29th January 2019” most closely resemble?

Model 3. 

Healthy Weston pre-consultation proposes the closure of 5 ICU level 3 beds. Are there plans to compensate for their lose by increasing ICU beds by a similar amount at the Bristol Royal Infirmary, Musgrove or the RUH hospitals or will these reduce the availability of ICU beds across the local area?

Under the detailed model of care we are consulting on, we are not proposing to close any critical care beds in Weston Hospital.  The existing 5 beds will remain in place as High Dependency Unit beds with the ability to step up to Level 3 critical care to stabilise and transfer patients when necessary.  The Healthy Weston clinical leadership group and Directors of Finance have confirmed that the transfer to neighbouring hospitals can be absorbed under current arrangements.

Can it be confirmed that the Healthy Weston programme has accounted for the potential increase in patient numbers on local health services due to such effects as the workforce introduced for the development of the Hinckley C power station and the expansion of passenger numbers at Bristol Airport?

Our proposals use the North Somerset population growth projections from the Joint Strategic Needs Assessment.  In completing the Joint Strategic Needs Assessment, local authorities calculate population growth based on a range of factors including new housing and industry.  Crucially, we have taken note that there will be particular increases in the older and younger age groups, which is why we are implementing the Integrated Frailty Service and extending the opening hours of the specialist paediatric unit.  

In the Healthy Weston Pre-consultation Business Case document, Appendix 15, page 14, the following statement is made: “National guidelines say A&Es like that at Weston Hospital should serve a minimum population of 500,000 people. This is significantly more than the 152,000 people it currently serves”.  It was stated at the Weston Area Health NHS Trust AGM presentation of September 2018 that Weston Hospital provided care for a population of approximately 270,000. Why does this estimate differ from that in the quote above. Could this be in part that the estimate of 152,000 does not include certain GP practices that regularly refer patients to Weston Hospital (i.e.; GP practices in Clevedon, Portishead and Nailsea) and also does not make any allowance for the effect of tourism on Weston Hospital?

The 270,000 figure would cover the entire population of North Somerset and North Sedgemoor, which in theory Weston Hospital could be called on to offer services for. However, the work of the Healthy Weston programme has looked at the actual usage of Weston Hospital by the local population, which is where the 152,000 comes from, being based on actual demand. The difference between the 2 figures is largely explained by the fact that people in the north part of North Somerset tend to look to Bristol for their care. The CCG pays each hospital on the basis of the activity they provide. In 2017-18, 42% of the CCG’s total spend on hospital care for North Somerset residents went to Weston Hospital. Another issue is that Weston, as a district general hospital does not provide a number of services for local residents within specialities such neuro and cardiac care, vascular, gynaecology, obstetrics and paediatrics. 

Regardless of any theoretical catchment area, what is clear is that activity in Weston Hospital is declining year on year, compared to neighbouring hospitals all of whom have seen an increase in activity.  We want to ensure that Weston Hospital is better able to provide high quality care for the population it serves, along with expanded primary and community care to keep people well and out of hospital wherever possible.  You can find more information about the population modelling work in Appendix 5 of the pre-consultation Business Case.

Can it be confirmed that the Guideline stated above is applied nationally across all services provided by NHS England and has been adopted by the Department of Health and Social Care and approved by NICE? If it is what percentage of A&E unit (Type 1 EDs) within NHS England do not meet this guideline?

We have been working closely with NHS England to ensure that we apply the latest policy guidance to the plans for Weston Hospital.  During this time, the NHS has also published its Long Term Plan.  The guidance that you refer to has been subsumed by the Long Term Plan, which incorporates guidance that is also outlined in the NHS Five Year Forward View and the associated Next Steps.  This guidance is clear that networks of linked hospitals should be developed to ensure patients with the most serious needs get to specialist centres. This draws on the success of major trauma centres, which have saved 30% more of the lives of the worst injured compared to other models of care.  The guidance goes further to suggest that smaller district hospitals should not be providing complex acute services where there is evidence that high volumes are associated with high quality.

In your media interviews regarding your proposals for the future of Weston General hospital, there was mention of a 24 hour crisis cafe. Could you explain what this is, how it would work and how the people in crisis would get to the hospital which is on the towns outskirts.

The idea of a crisis and recovery centre has come out of the Healthy Weston process of co-design involving local professionals, patients and the public. Open at evenings at weekends (but not 24 hours), it is designed to support people experiencing an acute mental health crisis and get them the right support and help to get them back on an even keel. We envisage the service being staffed by people from the non-statutory (charitable) sector with access to qualified mental health professionals for additional support where needed.

This type of service is based on other examples that have been set up and are running successfully elsewhere in the country. We expect to commission this service from around April of this year. Having listened to local people through the co-design process, we are looking to set this up in the centre of Weston because we know that the population it is designed to serve will find it easier to access there, compared to a service based on the hospital site.

In relation to the A&E, our objective is to provide effective and high quality 24 hour care for the people living and visiting the Weston area. However, local doctors who have led this process think we may be better able to do this differently to the ways we have done things in the past. We would encourage you to get involved in the consultation process once it is live and comment on these ideas and give your views.