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Learning from the Experience of Service Centralisation in Leeds

Learning from the Experience of Service Centralisation in Leeds. Dr Greg Reynolds Consultant Cardiologist Clinical Director Cardiology and Respiratory Medicine . First consultant appointment 1996, ST14 College tutor for 4 years (36 SHOs)

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Learning from the Experience of Service Centralisation in Leeds

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  1. Learning from the Experience of Service Centralisation in Leeds Dr Greg Reynolds Consultant Cardiologist Clinical Director Cardiology and Respiratory Medicine

  2. First consultant appointment 1996, ST14 • College tutor for 4 years (36 SHOs) • Cardiology Training Program Director (31 SpRs) Leeds and Hull based trainees • On call for Cardiology and for Acute Medicine 1:7 • Clinical Director for Cardiology (+Respiratory Medicine) since 2004 • Senior Clinical Leader role (SHA) Darzi • Choose and Book lead (SHA) • Joint chair Cardiology Redesign group (from old Long-term Conditions pathway group) NHS Leeds • Joint chair Public Health steering group NHS Leeds

  3. Reflection: I am quite good at spending other people’s money • Management style is by agreement • Community Heart Failure project 2003 £500K PCT expenditure on heart failure service • Cited by Leeds PCT as an example of good practice • Public Health £500K community service development 2010 NHS Leeds, website LeedsLetsChange • Cardiac redesign 2011, NHS Leeds commissioned blood testing program (BNP) £120K pa against future savings from the Acute Trust

  4. Leeds Hospitals • Leeds population 850,000 • Two main teaching Hospitals • Leeds General Infirmary (LGI) older, traditional, central Leeds, close to shops and restaurants • St James Hospital built on site of Victorian workhouse, huge bed base, poorer part of the city (LGI expensive cars an opportunity)

  5. United Leeds Teaching Hospitals • The two Trusts merged in April 1998 to become the largest single Hospital Trust in the UK • We all agree we are now one organisation • But of course St James (LGI) is better than LGI (St James) and always will be

  6. United Leeds Teaching Hospitals • This was a merger of Chief Execs and the Trust boards in April 1998 • In practice the name on the stationery changed but little direct effect on services • Most services still available on both sites • Became “Leeds Teaching Hospitals”

  7. Reflection on Trust merger • Scottish independence ? • Hostile takeover ? • Slap in the face with a wet fish ?

  8. Jubilee Building • Opened in late1998 • New building cost £90 million • Yorkshire Heart Centre built on the LGI site (+ neurosurgery) • In retrospect built on the wrong site

  9. Cardiology centralisation • A Cardiologist from LGI and a Respiratory Physician from St James were chatting in their local pub (Oct 2005) • Wouldn’t it be a good idea if my service centralised on my site….. • And most people agreed this would be a good idea • If the idea is right don't let existing cultures and prejudices dictate strategy

  10. Achieving Clinical Engagement

  11. LGI “Yorkshire Heart Centre” 14 Cardiologists 3 Respiratory physicians 74 Cardiology beds St James 5 Cardiologists 6 Respiratory Physicians 56 Cardiology beds Achieving Clinical Engagement

  12. SJUH Consultants view • But of course St James is better than LGI and always will be 5 consultants • My predecessor as Clinical Director • Professor of Cardiology • 3 very competent clinical cardiologists • This was an entirely competent clinical service

  13. Why change ? • The Trust Board say that patient safety comes first, but we all know that they only reward meeting targets which allow (us) to achieve Foundation Trust status • Was this simply a cost saving exercise ?

  14. SJUH Consultants view • Following a series of meetings 4 consultants accepted the rationale for change and were in agreement to work to achieve the goals of the organisation • One did not. A compromise solution was agreed with the Medical Director. The consultant has since retired.

  15. Achieving Clinical Engagement • Not everyone will agree, need opinion leaders on board* • Some solutions need high level external pressure (*The recent clinical engagement day I attended said you need complete agreement on why change is needed….)

  16. Planning service change

  17. Planning service change • 130 Cardiology beds cross-site became 100 beds on a single site • Immediate staff concern regarding loss of employment • Continued to provide clinics and a non-invasive service at St James only

  18. Staff groups • Doctors Intricacies of reorganising junior doctor rotas. More SpRs, less FY1s and SHOs • Nurses Closed one ward on each site with nursing redeployment very effectively supported by matrons • Technicians Agenda for change had recently caused major disruption, no additional losses

  19. Timetable First discussed Oct 2005 First meetings Jan 2006 Ward moves Sep 2006 • Planning groups, key players including Ambulance service • Consultant integration was easier to achieve than nursing integration

  20. Planning service change • Staff have a high degree of loyalty to the institutions in which they work and do not welcome change • Once the “tipping point” of accepting the inevitable was reached it became a straightforward planning process • We fully committed to the strategy

  21. The year that followed…

  22. The year that followed…. • We overprovided on the site that was losing the service A cardiologist was timetabled to spend their full day cross-site (Mon-Fri) A cardiology SpR was timetabled to spend their full day cross-site (7 days) • Initially the transferred Cardiology ward was in a separate block in old accommodation. This was a disaster requiring to be changed rapidly

  23. The year that followed • Benefits: £3million immediate annual cost saving on a budget of £45 million. • Services delivered efficiently with economies of scale • Consultants able to achieve sub specialist ambitions • Our average length of stay is 5.5 days compared to 6.5 days for peers

  24. None of the consultants would go back to how it was before • Managers see this as a successful merger • My ward sister preferred her previous ward but only since becoming a female ward

  25. The year that followed… • Cost savings achieved, quality maintained and increased efficiency achieved

  26. Other Service Centralisations • Following on from this many further reorganisations have occurred in Leeds • For 10 years a new Children’s Hospital was projected. • Leeds has struggled for years to balance the books • At a cost of £300 million this was deemed unaffordable

  27. A Children’s Hospital was achieved by reconfiguring services in existing accommodation • A major issue for the Children’s Hospital has been that obstetric services are on a different site requiring the provision of 2 Paediatric ICUs

  28. Orthopedic services have been split into elective services on a non-acute site and acute services in the Jubilee Building (Yorkshire Heart Centre) with a view to becoming a designated Trauma Centre

  29. Medicine Centralisation • Leeds has always struggled to achieve 4 hour access targets • The success of Respiratory / Cardiology centralisation was followed in Medicine division by centralisation of Acute Medicine and Elderly Medicine at St James • Same targets: economies of scale, cost saving, quality and efficiency

  30. Medicine Centralisation • Medicine centralised in Jan/Feb • Elderly Medicine in December • Complete withdrawal of services from LGI site, no RMO cover, Failed to look at organisational need, too focussed on local service need • Continuing bed crises • Some care of elderly services housed in old remote accommodation with issues about care standards • Lack of leadership: Insufficient Acute Medicine physicians to lead the service

  31. Medicine Centralisation • Not able to fully integrate neurology and acute stroke services on alternative site • Don't have the critical mass to deliver HASU (hyper acute stroke unit)

  32. (Medicine) Centralisation • Some services (Medicine, Stroke, Children’s services) have struggled because of split site services • Personal view: It would work better if all services were on one site, if it was affordable I would close my hospital and move to the workhouse site

  33. Finally, Regional Cardiology services and acrimony • Since 2006 the gold standard treatment for heart attack is an urgent angiogram and coronary stent (PPCI) • This requires a consultant cardiologist and cathlab team to be available acutely 24 hours a day • Leeds PPCI service covers Leeds, Bradford, York, Harrogate, Airedale, Wakefield, Dewsbury and Pontefract • Air ambulance • 1000+ cases per year • Population ~ 2.5 million • Leeds has 7 specialist consultants

  34. Regional Cardiology • Agreed that 8 LGI based consultants and 8-12 DGH based consultants would provide the service • Accommodation suggested that Leeds would pay hotel costs for DGH consultants, agreed to an on call room • Issue of fitness to work the next day and compensatory rest payment to the Trust • Total cost for consultant on call reckoned by DGH participants at £1.2 million pa

  35. Regional Cardiology rota • After a series of meetings we invited the Leeds Deputy Medical Director with responsibility for medical workforce issues to address the group • He was verbally abused and no conclusion reached

  36. Regional Cardiology rota • We invited the Medical Director of the SHA to chair the next meeting • General level of tension lessened • After a couple more meetings agreement was reached with the DGH employing Trusts with terms and conditions that were mutually acceptable

  37. Regional Cardiology rota • It is now all sweetness and light • Some solutions need high level external pressure • It’s not personal

  38. Conclusions • Service centralisation can bring clear benefits • Staff have a high level of loyalty to their institution • Cross site working is challenging because of the interdependencies of different services • Senior Medical engagement is absolutely necessary • Some solutions need high level external pressure from within or without the organisation

  39. Conclusion • It’s not personal (usually) • Thank you

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