Archived decisions

Contact: Denise Holden ex 7338

e-mail: [email protected]

1. Summary and Purpose

1.1. The purpose of this report is to alert Members to proposals from the NHS to vary or develop health services provided to people living in the area of the Committee.

1.2. Proposals that are considered to be substantial in nature will be subject to formal public consultation. The nature and scope of this consultation should be discussed with the Committee at the earliest opportunity.

1.3. The response of the Committee will take account of the Framework for Assessing Substantial Change and Variation in Health Services agreed by the Hampshire, Isle of Wight, Portsmouth and Southampton Joint Committee in March 2005. This places particular emphasis on the duties imposed on the NHS by Section 11 of the Health and Social Care Act 2001.

1.4. This Report is presented to the Committee in 2 parts:

_ Items for information: these alert the Committee to forthcoming proposals from the NHS to vary or change services. This provides the Committee with an opportunity to determine if the proposal would be considered substantial and assess the need to establish formal joint arrangements

_ Items for action: these set out the actions required by the Committee to respond to proposals from the NHS to substantially change or vary NHS services.

1.5. This report and recommendations provide members with an opportunity to influence and improve the delivery of health services in Hampshire and therefore

support the delivery of the Corporate Strategy aim of maximising well being.

Items for Information

2. Review of Maternity Services in South West Hampshire

2.1. SUHT has confirmed that, due to a delay in the rehabilitation services moving from the Ashurst site the opening of the new centre will be delayed until the autumn.

Recommendation

2.2. Members note that this work is now progressing.

3. South Central SHA: Review of Community Hospitals

3.1. No community hospitals in the Hampshire County Council area were put forward in the bid for capital funding put forward by the SHA.

Recommendation

3.2. That the Committee is kept apprised of progress with this work

Items for Action

4. West Sussex PCT: Acute Service Reconfiguration

4.1. The Joint HOSC has referred the content and conduct of the consultation process undertaken by West Sussex PCT to the Secretary of State. His response confirms that he will be seeking the advice of the Independent Reconfiguration Panel on the matter. It is not known what the timeframe for receiving this advice will be. A summary of the evidence provided by Hampshire to inform this process is attached at Appendix One.

4.2. In the meantime the West Sussex PCT has declined the request from the Joint HOSC to suspend the consultation pending the outcome of the Secretary of State's decision.

4.3. The Joint HOSC is running a series of themed Select Committee Style meetings covering A&E services, maternity and paediatric services and community services. Additional meetings have been set up to allow MPs, district and borough councils, P&PIFs and other leading stakeholders to share their views about the proposals. Hampshire and Portsmouth are taking the lead in briefing members on key lines of inquiry relating to A&E services. A copy of the summary points from the draft briefing note is attached at Appendix Two.

4.4. West Sussex have employed independent consultants to provide advice on finance and other issues relating to the proposals.

4.5. The most recent up-date from West Sussex PCT and consultation document is available at http://www.southeastcoastfff.nhs.uk/Home/West-Sussex.aspx . Hard copies of the proposal were received in the scrutiny office on 18 August and will be tabled at the meeting.

4.6. Hampshire District Authorities, MPs and P&PIF have been kept apprised of the Hampshire HOSC's involvement and views.

Recommendation

4.7. Members are kept apprised of the progress of the Joint West Sussex HOSC.

5. Maternity Services in South East Hampshire

5.1. The PCT launched its formal consultation on these services and members should have received individual copies of the proposals in the week commencing 16 July. The consultation will conclude on 31 October.

5.2. East Hampshire HAT has indicated its support for the options that include the Grange at Peterfield.

Recommendation

5.3. Members highlight any additional action to be taken by the PCT with regard to improving the consultation process.

5.4. Any comments on the options presented are shared with the Chairman and the scrutiny office by 12 October 2007.

5.5. Members receive an analysis of the feedback from local people about the options presented and proposed way forward at the meeting in November.

6. Surrey PCT- Fit for the Future- Commissioning Intentions

6.1. The HOSC has been notified that Surrey PCT intends to go to consultation on its Commissioning Intentions for specialty services after its Board meeting on 25 September. These are included at Appendix Three. A further letter to the Surrey HOSC, providing additional detail of the benefits and impact of the changes is attached at Appendix Four.

6.2. A subsequent meeting with the Chairman and senior representatives from the PCT on 12 September confirmed the following:

_ Surrey PCT is in the process of finalising the business case for the changes proposed, this would be shared with the HOSC as soon as it is finalised.

_ Local stakeholders have been able to feed into and inform the commissioning intentions

_ Local Trusts have been asked to set out how they provide services that meet the standards set out by the PCT.

_ There has been a strong clinical lead in shaping the proposals and good clinical networks are in place.

_ Hampshire PCT, Adult Services and Children's services need to be engaged as the process rolls forward to ensure that any changes that impact on service delivery in Hampshire can be taken into account.

_ Further work will take place with GPs and community service providers across the area affected.

_ The proposals represent the first stage of a rolling programme that will be regularly reviewed and refined.

_ The need to engage with a range of local stakeholders, including district Councils was recognised

6.3. The impact on Hampshire residents as a result of the changes proposed are as follows

_ Vascular services- no change is anticipated. The are also strong clinical networks with Basingstoke and North Hampshire NHS Foundation Trust

_ Cardiac services- no change is anticipated

_ Renal services- potential marginal impact on Hampshire residents as patients will be able to be treated more locally

_ Maternity Services- no change for Hampshire residents but potential for improved consultant cover in services used by local people.

_ Children's services-it is anticipated that there will be improvements in these services

_ Stroke services- it is anticipated there will be improvements in these services. These changes may impact on Hampshire residents

_ Emergency Surgery- no change for Hampshire residents

6.4. The Chairman noted that, where the changes were clearly going to improve services, and there had been robust local stakeholder engagement, the HOSC may look favourably on a foreshortened consultation period- although this would need to be discussed with Surrey HOSC and would be dependent on members being clear about the changes proposed. The full business case would allow the HOSC to determine if the implementation of the proposals is likely to have a substantial impact on people in the County. Should this be the case a formal Joint Committee would need to be established with Surrey.

Recommendations

6.5. Members receive a copy of the full business case when this is provided to determine if the changes proposed are substantial.

6.6. If changes are considered to be substantial a formal Joint Committee be established with Surrey HOSC.

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents that disclose exempt or confidential information as defined in the Act.

File Location

None

Appendix One

Please note the Appendices referred to in the table are not attached but are available via the scrutiny office

Appendix Two

Joint Health Overview and Scrutiny Committee for West Sussex

Proposals for Accident and Emergency Services

Key Issues Briefing Note for Members

1. Summary

1.1 There is a strong case to support the streaming of some conditions, such as heart attacks or major trauma patients to a specialist facility, detouring to a less specialist unit could adversely affect the outcome for this category of patient.

1.2 There is evidence to suggest that that alternatives to A&E (e.g. urgent care centres, minor injuries units) do not have a significant impact on the pressures in A&E- rather these seem to meet an unmet need.

1.3 Access to specialist input may not require a physical location, models of care based on clinical networks, appropriately supported by agreed protocols can provide a significant proportion of the support required.

1.4 The A&E Department is just one element of a range of different services that are able to provide effective emergency/urgent care, it cannot therefore be considered in isolation of other services- such as those in the community or ambulance services.

1.5 There is strong evidence supporting actions that can be taken across a health economy to address some of the areas that cause pressures on A&E- e.g. admissions due to falls, management of chronic disease but these need to be taken forward with explicit investment in community/primary care services.

1.6 Although there is evidence that many cases attending A&E could be treated in alternative settings it is more difficult to identify these prospectively prior to presentation.

1.7 Services for older people, children and those with mental health conditions need particular consideration in terms of using the A&E services.

1.8 There are particular issues related to rural populations that require recognition in order to balance the preferred critical mass of population with access needs.

1.9 Clinical interdependencies are key to draw out and address- the current proposals only focus on the population within the SHA boarders. It is not clear if the clinical interdependencies that transcend the SHA boundaries have been considered.

1.10 The demand for A&E is predictable, as is the need for critical care in specialist centres. This needs to underpin service planning.

1.11 Alternative care settings need to be part of a single clinical network, with clearly defined protocols for ensuring that patients receive timely and appropriate care.

1.12 Services, such as theatres, and diagnostics need to be considered on the basis of a 7 rather than a 5-day week in order to utilise resources services to the fullest extent.

Appendix Three

Proposed Acute

Commissioning Intentions

June 2007

Table of contents

Introduction 3

Summary 4

Key specialty areas 6

Vascular 6

Cardiology 7

Stroke 8

Maternity 9

Paediatrics 10

Renal 10

Emergency Surgery 11

Introduction

Surrey Primary Care Trust desires to commission high quality healthcare that is evidence based and meets appropriate professional standards to optimise healthcare outcomes for our population.

Surrey PCT has inherited healthcare services delivered to discrete parts of the population largely based on historical referral pathways to the local "district general" style hospitals. Various strategic approaches have been made by commissioners over the years to develop services. Probably the most successful has been the area of cancer services where the NHS Cancer Plan has enabled the networking, localisation and centralisation of various cancer related healthcare services.

Surrey PCT has reviewed services delivered to our population against the clinical evidence base and the professional guidance and standards produced by royal colleges and other professional bodies. The implications for commissioning supported by the evidence are described below. The potential effect of the European Working Time Directive is not considered here but is likely to have implications for all service providers.

We also need to respond to the changing needs of our local population. External factors which have also informed our thinking include:

_ Population growth: in 2005, Surrey estimated to have a population of 1,075,500. Projections are that there will be 1,104,200 million people in surrey by 2011 - growth of 2.35% on the 2006 population estimate

_ Ageing population: those aged 65 and over is projected to increase in both england and in surrey, albeit from 2010 at a slower rate in surrey

_ Average life expectancy: is significantly better than england average but there is a 5.4 year gap between those living in the fifth of wards with the highest life expectancy and those living in the fifth with the lowest levels

We have to respond to all these drivers to ensure we continue to provide healthcare that meets the needs of all our population in the future.

Summary

Having considered a range of local, national and international clinical evidence, we plan to commission services for a number of specialty areas as follows:

1. Vascular services: evidence that vascular services require a minimum population of one million to provide a robust service

Our commissioning intentions:

· for a hub and spoke service across the county

2. Cardiology: evidence that ready access to primary angioplasty following a heart attack improves clinical outcomes

Our commissioning intentions:

· for a specialist cardiology service, based in at least two Surrey locations, providing all urgent angioplasties and specialist emergency care.

3. Stroke services: evidence that providing rapid access to specialist stroke services and specialist rehabilitation saves lives and reduces disabilities

Our commissioning intentions:

· to commission services that meet the national clinical guidelines for stroke, ensuring patients have rapid access to and early CT/MRI scanning at dedicated stroke units with further access to specialist stroke rehabilitation.

4. Maternity services: evidence that moving from a consultant led to consultant delivered service improves clinical safety and outcomes

Our commissioning intentions:

· consultant delivered maternity services, in line with royal college guidelines, with:

o community services for low risk pregnancies

o hospital services for high risk pregnancies

5. Paediatric services: evidence that supports providing specialist paediatrics from specialist centres and local services

Our commissioning intentions:

· to only commission services that meet national professional quality standards

6. Renal: evidence that the increasing numbers of renal patients within Surrey is enough to sustain a specialist service within Surrey

Our commissioning intentions:

· to provide a specialist renal service within Surrey

7. Emergency surgery: evidence that local service providers deliver to the highest set of standards based on best practice.

Our commissioning intentions:

· Dedicated emergency teams separated from elective commitments.

· Dedicated emergency theatres over an extended working day

· Surgical Assessment Unit (SAU) provision

Key Specialty Areas

In more detail, our commissioning intentions for the eight specialty areas we are concentrating on are described below:

1. Vascular Services

Conclusion

· vascular services require a minimum population of one million to provide a robust service

National professional guidance is explicit about population size, workload and on call commitments. Emergency work forms a substantial proportion of surgical admissions and a major component of the workload for vascular surgeons. Emergency vascular problems comprise acutely ischaemic (bloodless) limbs, leaking abdominal aortic aneurysms, and a number of other conditions including vascular trauma.

There is also good evidence that patient outcome is not related to the distance travelled when they are transported to a centre where vascular expertise is available. The most severely ischaemic limbs require treatment within about six hours of onset if significant permanent damage is to be avoided. The transfer of patients with leaking aortic aneurysms has no effect on overall mortality. Evidence suggests that patient mortality after a ruptured aortic aneurysm may be as high as 95% if they stay in a hospital under the care of a non-vascular surgeon, compared to as low as 35% if they transfer to a vascular centre. The only exception is the patient who suffers a cardiac arrest on presentation; as such patients are unlikely to survive either the transfer or any subsequent surgery on the vascular unit.

Vascular surgery relies on close working relationships with a range of medical and surgical specialties especially cardiac, diabetic, renal, radiology and pathology. The 2007 Vascular Surgical Society document "The Provision of Emergency Vascular Services" provides guidance on the setting up of emergency vascular services which should include surgical and radiological expertise. The emergency service needs to be organised to allow reasonable elective activity to exist alongside an emergency on call rota of 1 in 6 or more for vascular surgery and interventional radiology. Hospitals providing an emergency vascular service should be able to demonstrate arrangements for urgent vascular imaging and interventional radiology at all times of the day and night.

Evidence suggests an average of 90 vascular operations per 100,000 population per year is required. 30 day mortality rate reduces in relation to hospital and surgeon volume, particularly in the treatment of ruptured aneurysms.

Our commissioning intentions

Surrey PCT intends to commission a single, Surrey based, vascular service for its population. This should include a hub and spoke model, with outpatient and non invasive investigations occurring as locally as possible and clinically appropriate, with the complex surgery and interventional investigation occurring at the hub of the network.

2. Cardiology

Conclusion

· that ready access to primary angioplasty following a heart attack improves clinical outcome

Treating heart attack victims with primary angioplasty in specialist treatment centres can save lives, even if this means a longer travel time. For example, one study in the US found that 30-day mortality rates are reduced from 11.4% to 4.9% if a patient is treated with primary angioplasty vs. in-hospital thrombolysis. Roger Boyle, in Mending hearts and brains, goes on to add that in the future, primary angioplasty undertaken in specialist centres may become the first treatment for heart attacks.

Coronary heart disease remains the most common cause of death in Surrey.

Local development of cardiac services, via the two Surrey cardiac networks, has been designed to meet standards set out in the Coronary Heart Disease National Service Framework (published in 2000).

In the past, many people died from their first heart attack; today, heart disease is a long term condition that can be managed. Key to this is the emergency treatment of heart attacks, using clot busting drugs. A newer treatment is the introduction of balloon angioplasty as an emergency procedure which reopens the blocked blood vessel. Evidence supports ready access to angioplasty to improve clinical outcome (see above). However, early thrombolysis (clot busting drugs) remains the current cornerstone of emergency treatment.

Most of our patients who do receive interventional angioplasty have this done in London (mainly at St George's), but delivered by Surrey consultants. This is an opportunity to move work back into Surrey, as we already have the skilled workforce we need. This move already has the backing of one of our two cardiac networks. Some infrastructure is already in place which could be developed towards a specialist service.

Our commissioning intentions

To commission emergency and elective cardiac care within Surrey that meets the required national and clinical standards, including:

· coronary syndromes

· ST elevation myocardial infarctions (heart attacks)

· pacing and acute rhythm disturbances

Evidence shows that in order to benefit, patients need to receive emergency angioplasty within 90 minutes from calling for an ambulance. To meet this critical time, we need a minimum of two sites within Surrey.

During 2005/06, Surrey had 520 ST elevation heart attacks and 3,447 non emergency interventions other than surgery. This workload could sustain a maximum of 10 consultants, so a full 24 hour, 7 day a week emergency service is not sustainable. As part of our commissioning, we would expect providers to identify how they plan to provide a 24 hour, 7 day a week service as an incremental development.

3. Stroke Services

Conclusion

· providing rapid access to specialist stroke services and then into specialist rehabilitation saves lives and reduces disabilities

The benefits of rapid access to diagnosis using early CT or other scans to establish the correct diagnosis and hence enable appropriate treatment are well established. Locally based rehabilitation has also been shown to provide the most positive outcomes. This rehabilitation can be inpatient based although there is evidence to support early discharge with home based rehabilitation.

Our commissioning intentions

Surrey PCT intends to commission stroke services that meet the National Clinical Guidelines for Stroke (2004) and which have recently been used as the standards for the 2006 National Stroke Audit. Thus to ensure patients have rapid admission to and early CT/MRI scanning at dedicated stroke units where they spend at least 50% of their hospital admission, with further access to specialist stroke rehabilitation. The criteria also include:

o access to brain imaging within 24 hours and

o access to <3hours thrombolysis for appropriate cases

o screen for swallowing disorders within 24 hours

o aspirin started within 48 hours

o physiotherapy assessment within the first 72 hours

o occupational therapy assessment within 7 days and

o home visit before discharge

4. Maternity Services

Conclusion

· moving from a consultant led to a consultant delivered service improves clinical safety and outcomes

Based on Royal College guidance evidence supports:

· units delivering more than 4,000 births per year should have 60 hours a week consultant cover by 2008

· with a move to 168 hours by 2010 with a midwife to woman in labour ratio of 1.2 to 1.4 to 1

· smaller units should have minimum of 40 hours per week

· obstetric units also require dedicated obstetric anaesthetic services

How services are delivered now

Surrey maternity units are based in acute hospitals and are predominantly consultant led. Surrey hospitals deliver up to 18,000 births a year, with around 5,500 births `imported' from the surrounding areas.

Ashford & St Peter's, Frimley Park, Royal Surrey County and Surrey & Sussex Healthcare trusts currently deliver around 4,000 births per year. At the Epsom site of Epsom & St Helier trust, the number of births is less than 2,000 a year, with consultant obstetric cover available for 24 hours a week. The trust has proposed to centralise maternity and paediatrics on its St Helier site, subject to formal consultation.

Our commissioning intentions

Surrey PCT intends to commission according to royal college standards to ensure the highest quality service is available to Surrey mothers. We also need to ensure there is equitable access to services for mothers across the county and at the same time, ensure maternal choice.

Neo-natal intensive care (NICU)

Aligned to maternity services for high risk pregnancies is NICU. The 2003 report of the Department of Health expert working group on neonatal intensive care services recommends that hospitals work together in formal, managed networks including the designation of some hospitals equipped to care for the sickest and smallest babies, with other hospitals providing high dependency care and shorter periods of intensive care as close to home as possible. Typical networks were modelled on 18,000 births.

St Peter's Hospital currently provides a level III NICU which meets the required standards for medical staffing and covers a large enough population base outside Surrey with retrieval and ambulance services to be sustainable. Between 125-375 babies born in Surrey each year will require neonatal intensive care.

5. Paediatrics

Conclusion

· evidence supports providing specialist paediatrics from specialist centres and local services as locally as possible.

This needs to be seen in the context of the relatively small number of paediatric admissions within Surrey, and the need for a sustainable, high quality consultant delivered service.

Our commissioning intentions

Surrey PCT will be looking to only commission paediatric services that meet national professional quality standards. This is of particular relevance for emergency paediatric services which should comply with the Recommendations of the Report of the Intercollegiate Committee for Services for Children in Emergency Departments (2007).

6. Renal

Conclusion

· to provide a specialist renal service within Surrey

The clinical need for renal care is rising and will continue to do so with the increasing age and obesity of the population. It is estimated that Surrey could expect an incidence of about 60 to 80 new cases of people needing renal support a year. This is adequate in clinical terms to sustain a Surrey based service.

The Renal National Service Framework sets out the evidence based care expected to be delivered for the population, without specifying a minimum population base.

Specialist renal services are currently provided to the Surrey population from London. Much of this is provided as outreach, with both outpatient clinics and satellite dialysis units across Surrey. This is commissioned by Surrey PCT, but provided by St Helier staff. Inpatient facilities and supportive surgery occurs at St Helier Hospital, with transplantation taking place at St George's, Tooting.

Our commissioning intentions

We want to commission services for an inpatient, renal facility (excluding transplantation) within Surrey.

7. Emergency Surgery, Trauma and Orthopaedics

Conclusion

· Dedicated emergency teams separated from elective commitments.

· Dedicated emergency theatres over an extended working day

· Surgical Assessment Unit (SAU) provision

Surrey PCT intends to commission acute surgical services that comply with nationally recognised clinical, professional and quality standards¹.

Publication of `best practice' guidelines for emergency and elective surgical care are expected imminently from the Royal College of Surgeons (RCOS) and a national urgent and emergency care strategy, due for publication shortly, is currently being developed (Alberti 2007). Both these documents will be drawn upon to inform and align Surrey PCT commissioning activity in this area.

However consistent guidance already exists (e.g. NCPOD 2006) on the need for three key elements of emergency surgery, T&O care; dedicated emergency teams (with no elective commitments), dedicated emergency theatres over an extended working day, and Surgical Assessment Unit (SAU) provision. This will provide an initial set of key standards around which the PCT will set its commissioning intentions in these service areas.

Equally, guidance exists (itself in line with the general policy direction of a patient led NHS) on models of care for emergency and urgent care services. In summary this suggests that; fast convenient services, delivered more locally and shaped around people's needs and preferences will be supported by safe, well integrated emergency and urgent care networks and specialist services which go across organisational boundaries.

Thus, the shift to more community based care will form an important component of how emergency / urgent care networks are structured, whilst at the same time appreciating that not every A&E department can do everything. Certain services, such as major trauma may be best provided in a smaller number of regional specialist centres, allowing optimal provision of high quality services (Alberti 2007) i.e. giving the best possible treatment to the sickest people since the sooner specialist treatment is started in the right setting outcomes improve (see for example, Boyle 2006 & Alberti 2006).

Additional guidance (RCOS 2006) highlights the necessity for on-site surgical opinion to be accessible alongside unselelected medical take and also that elective and emergency services should remain on the same site (RCOS 2007).

The Local Hospitals project (2006) identifies a set of principles to guide the future shape of delivering emergency care and also promotes the concept of emergency care networks that can ensure prompt access to other important services at local hospitals. Emergency surgery and trauma (alongside specialist surgery, obstetrics and gynaecology, paediatrics etc) will be provided via well defined and accountable multi-hospital networks with mutual support and interdependence becoming essential where key service areas become difficult to sustain on a 24 hour basis at every local hospital.

As an initial stage in this evidence driven approach to commissioning, current provision will be reviewed against these standards and guidelines and the extent to which local services comply, identified. These standards, which will be clearly stated, will represent the key parameters of the PCTs commissioning criteria.

From the evidence that the PCT currently has, however, there would appear to be we some distance to travel before we can be confident that emergency service provision reflects the highest clinical standards and best practice and that and the safest possible configuration of services is being offered to the population of Surrey. For example:

· NCPOD standards: not all our local providers are fully compliant, for example, the separation of surgical emergency and elective care;

· networked emergency care provision is still at an early stage of development; and

· the potential to delivery services locally has not been fully appraised and the extent to which services can be appropriately shifted to `closer to home' unidentified.

Our Commissioning Intentions

To use the commissioning process to improve the quality, safety and accessibility of emergency surgery and trauma services in Surrey.

Appendix Four : Letter from Surrey PCT to Surrey HOSC re: Commissioning Intentions- 7 September 2007

Further to my letter of last week regarding our intention to proceed to public consultation at the end of September (subject to a quality assurance process by South East Coast Strategic Health Authority) and discussions between our officers, I believe it would be helpful to outline our proposals and thinking in advance of our formal meeting for you and your committee members.

Before I go into the detail, I would wish to reassure members that we are planning a major communication programme on the scale of full public consultation to fully communicate the proposed improvements given the cynicism and beliefs held regarding closure of services. However, we need to be clear and honest with Surrey residents, what we are asking them in consultation - what they can influence and what they cannot - and how the PCT will then arrive at its decisions.

I will send the full case for change documentation ahead of the 20 September meeting and have agreed with your officers, that this will be dispatched on 13 September, direct to all the members of the committee in readiness.

Brief summary of the Fit for Future proposals

The Fit for the Future programme is a fore-runner of the Surrey Primary Care Trust's strategic commissioning plan. It adopts an evidence-based approach to improving clinical standards in seven acute specialty areas. As a first step, it is intended to begin to ensure that all commissioned services in Surrey meet the needs of patients and are of consistent quality across the county.

The proposed improvements are based on the best clinical evidence and guidance available. Most importantly, it is intended to put the patient at the heart of the commissioning process. The seven areas of acute service delivery examined by Fit for the Future are:

· Vascular

· Cardiac

· Renal

· Maternity

· Paediatric

· Stroke and;

· Emergency surgery

For each area, Surrey PCT developed a set of commissioning intentions which set out the clinical standards (based on the latest clinical evidence) and quality requirements expected of hospitals providing each of the seven services. All the acute hospitals in Surrey have responded to the commissioning intentions setting out whether they can comply and whether compliance would require them to reconfigure their services.

1 Proposal for vascular services

A networked vascular service for Surrey

Provider response

Royal Surrey joins the Surrey Vascular Group

Extends day and emergency vascular service to all acute trusts in West Surrey

Epsom hospital and Surrey and Sussex (SASH) remain part of the St George's vascular network

What changes?

All vascular surgeons in West Surrey work as part of a single networked service

Daycase vascular surgery at the Royal Surrey is provided as part of the Surrey Vascular Group and no longer by a stand-alone surgical rota

Transfers of west Surrey patients to St George's,Tooting will be reduced

No change in service at SASH and Epsom - out of hours, patients will continue to be referred to St George's

Benefits

Full out of hours vascular cover for all patients in West Surrey - the vascular surgeon will either travel to the patient or the patient will be admitted at one of the emergency vascular centres (Frimley and St Peter's)

Reduced referrals to London for treatment

Greater availability of vascular surgeons to support other surgical procedures (often major trauma)

Impact

Joining the local vascular network means that instead of being taken to London, patients in West Surrey requiring emergency vascular surgery will be treated at to Frimley or St Peters.

Surrey PCT intends to formally consult on this proposal as the impact on patients is considered a substantial development to service.

2 Proposal for cardiac services

A single cardiac network in Surrey providing treatment for heart attacks and other coronary conditions

Provider response

To ensure patients who need emergency angioplasty (balloon dilation of the heart vessels) within 90 minutes, a minimum of two specialist sites is needed

The trusts will develop a single Surrey cardiac network proving extended day cover (8am -8pm) with:

One centre at SASH

Co-ordinated service at Frimley and St Peter's

What changes?

Bring more invasive and interventional heart services from London into Surrey for the majority of conditions

Epsom hospital remains part of the South West London network (linked to St Helier and St George's)

Benefits

Brings care closer to home for heart attack patients needing specialist cardiac treatment

Reduced length of stay in hospital

Reduced referrals to hospitals in London

Impact

More Surrey patients requiring specialist heart treatment can be treated at SASH, Frimley or St Peters rather being taken to London.

Surrey PCT intends to formally consult on this proposal as the impact on patients is considered a substantial development to service.

3 Proposal for renal services

Develop a specialist kidney inpatient service in Surrey

Provider response

The PCT will lead on developing options for bringing acute kidney care back into Surrey and selection of a suitable site within Surrey

What changes?

Outreach and chronic dialysis services are provided in Surrey by Epsom and St Helier NHS Trust as part of the South West London Renal Service

A full inpatient service will be available in Surrey for the first time, including acute dialysis

Transplant surgery will remain at St George's but linked into the renal service in Surrey

Benefits

More access to renal care in Surrey in particular for acutely ill patients

Easier, more local access to renal specialists at early stages of treatment

Less travel to London for Surrey patients - often three times a week for patients with renal failure who need acute renal dialysis.

Impact

Patients with early kidney disease or who are very ill will be able to have treatment in Surrey rather than travel to St Helier hospital in Carshalton.

Surrey PCT intends to formally consult on this proposal as the impact on patients is considered a substantial development to current service.

4 Proposal for maternity services

The provision of maternity services in line with Royal College guidelines

Provider response

The four Surrey trusts will provide consultant-led maternity services that are compliant with Royal College guidelines ie units delivering more than 4000 babies a year should have 60 hours of consultant presence by 2008 and 98 hours by 2009.

What changes?

An increase in consultant presence on each of the labour wards

Enhanced service by co-locating midwife-led units at SASH, St Peter's and Frimley

* Further joint work to agree options for Epsom and St Helier hospitals in light of the `Framework for Action' pan-London consultation

Benefits

Greater presence of trained and experienced doctors will deliver a clinically safer service

Co-locating midwife-led units will provide mothers with more choice

Impact

A higher quality of care and choice of care can be offered to Surrey mothers as a direct result of increased consultant presence and development of midwife-led units. As a result of this proposal, no patient will be required to travel further or change current location of service.

Surrey PCT believes a communication programme to support the benefits of the enhanced service with speedy implementation is in the best interests of the population.

5 Proposal for children's services

Surrey PCT will commission paediatric medical services that meet national professional quality standards and emergency paediatric services should comply with the Recommendations of the Report of the Intercollegiate Committee for Services for Children in Emergency Departments (2007).

Provider response

No change to acute children's services in Surrey trusts however the trusts propose to meet the professional recommendations by increasing staffing levels.

What changes?

All hospitals continue to provide both in and outpatient children's services addressing any shortcomings against the report into emergency departments mentioned above. For example, ensuring dedicated emergency facilities with paediatric specialists so that emergency care for children is of the same standard as that for adults.

Benefits

Children and their families will benefit from an increasing focus on high standards of service provision. Meeting the exacting quality standards will ensure children are seen by doctors and nurses specifically trained in paediatric medicine which will mean even safer care for children.

Dedicated children's services also benefit maternity units where resuscitation of babies is critical to safe delivery of care.

Impact

Increased quality of care can be offered to Surrey families as a direct result of meeting higher quality standards. As a result of this proposal, no patient will be required to travel further or change current location of service.

Surrey PCT believes a communication programme to support the benefits of the standards with speedy implementation is in the best interests of the population.

6 Proposal for stoke services

Surrey PCT will commission stroke services that meet the National Clinical Guidelines for Stroke (2004) which have recently been used as the standards for the 2006 National Stroke Audit. As a result we wish to commission:

· Dedicated stroke units

· 24/7 access to CT scan within three hours

· Access to clot busting treatment (thrombolysis)

· Investigation of minor strokes within seven days

Provider response

All Surrey trusts have committed to develop stroke services that meet the standards in 2008

What changes?

Currently, no Surrey provider achieves the top quartile ranking for its acute stroke services (National Stroke Audit). All west Surrey service providers will meet the standards by April 2008 and SASH will meet the standards by December 2008. This means all patients will have access to 24/7 CT scanning and expert opinion to ensure thrombolysis can be administered within three hours where appropriate.

Benefits

Improved access to CT scanning and expert opinion regarding thrombolysis therapy means patients have the maximum chance of recovering their independence after a stroke. Treatment in a dedicated stroke unit and thorough investigation of minor strokes in seven days means that permanent damage as a result of a stroke can either be prevented, or minimised wherever possible.

Impact

Increased quality of care can be offered to Surrey patients as a direct result of meeting these stringent quality standards. As a result of this proposal, no patient will be required to travel further or change current location of service.

Surrey PCT believes a communication programme to support the benefits of the standards with speedy implementation is in the best interests of the population.

7 Proposal for emergency surgery services

A. Surrey PCT will commission acute surgical services that comply with the nationally recognised clinical, professional and quality standards outlined in the full case for change documentation (includes recommendations by the National Confidential Enquiry into Patient Outcome and Death or NCEPOD). As a result the commissioning intention requires:

:

· Dedicated emergency teams separated from planned or elective commitments

· Dedicated emergency theatres over an extended working day

· Surgical assessment unit provision

Provider response

All Surrey trusts will continue to provide emergency surgery supported by a comprehensive emergency medical take on all four major sites. All trusts confirm they will comply with the clinical standards set out by the PCT based on NCEPOD guidance.

*Epsom hospital no longer admits patients for emergency surgery

What changes?

In meeting the higher quality standards some investments are required to ensure separation of theatres over a longer working day for example, as well as providing surgical assessment units.

Benefits

Most Surrey trusts meet these standards but some small investment by RSCH will mean those patients treated there will have even faster access than before

Reduces the impact on planned surgical care - fewer cancellations of booked surgery

Impact

Increased access can be offered to Surrey patients as a direct result of meeting these stringent quality standards. As a result of this proposal, no patient will be required to travel further or change current location of service.

Surrey PCT believes a communication programme to support the benefits of the standards with speedy implementation is in the best interests of the population.

I hope that this summary helps explain the improvements that the PCT, together with our NHS partners wish to see Surrey patients benefitting from. We have an exciting opportunity to really promote these advantages and I trust that the committee will agree with many of our Co-Design colleagues, to simply "Get on with it".