Archived decisions

Agenda item 5

HAMPSHIRE COUNTY COUNCIL

Report

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. Winchester and Eastleigh Healthcare NHS Trust: Outpatients Department relocation and future developments

2.1. WEHT will provide an update for Members about the proposed move of the outpatients department to Avalon House and other plans for the future.

2.2. Should the Trust indicate an intention to proceed with relocating outpatients the HOSC has specifically asked that the following points are taken into account:

_ Access, including car parking and access for people with a disability or using public transport

_ The supporting diagnostic and other services to be provided on the site (e.g. phlebotomy, x-ray) and the logistics to relocating these to a distant site

_ The need for clear patient's pathways to ensure that patient flows are easily planned and managed. Not all out-patient consultations would be suitable for a remote site

2.3. Cllrs West, Collin and Mutton met with the Trust Chief Executive on 2 September in their capacity as the key links for the HOSC in relation to WEHT.

Recommendations

2.4. That the Trust , through the nominated Cllrs, maintains regular contact with the HOSC and reports back formally on future developments as plans are developed.

3. Winchester and Eastleigh Healthcare NHS Trust: Provision of surgical dermatology services

3.1. WEHT have given notice of their intention to discontinue services for surgical dermatology following the retirement of the specialist surgeon.

3.2. The Trust is currently liaising with the NHS Hampshire to determine how these services will be provided in the future

Recommendation

3.3. Members agree if the changes proposed constitute a substantial variation in service delivery.

Items for Action

4. Hampshire Partnership NHS Foundation Trust: Proposals to modernise adult mental health rehabilitation.

4.1. Hampshire Partnership has set out a range of proposals for modernising mental health rehabilitation services (see Appendix One).

4.2. The HOSC will need to consider if the proposals constitute a substantial service change and if so how it wishes to scrutinise:

_ The engagement and involvement of key stakeholders in developing the proposals

_ Plans for formal consultation

4.3. Additionally the HOSC will be required to determine if it considers that the agreed way forward is in the interests of the population affected.

Recommendation

4.4. That the HOSC agrees its response to the proposals service change, taking account of 4.2 and 4.3 above.

5. Surrey and Borders Partnership NHS Trust: Proposals to reconfigure 24 hour assessment and treatment (inpatient mental health services)

5.1. At the HOSC meeting on 31 March 2009 Members expressed a number of continuing concerns about proposals from Surrey and Borders NHS Foundation Trust to reconfigure inpatient mental health services to three sites based in Surrey.

5.2. Key stakeholders, including local district councils and patient groups also expressed concerns about the proposals.

5.3. NHS Hampshire and HCC Adult Services have indicated that they are supportive of the broad direction of travel proposed by the Trust.

5.4. The Trust has written now written to the HOSC indicating its intention to proceed with the reconfiguration of inpatient services to the 3 sites in Surrey. The published outcome of the consultation, and the correspondence from the Trust are attached at Appendices Two and Three respectively.

5.5. Key stakeholders have been asked for views on the decision of the Trust to proceed.

Recommendations

5.6. The HOSC notes the strong support in Surrey for the planned changes and acknowledges the efforts of the Trust to engage with stakeholders as fully as possible in the latter part of the consultation exercise. Taking these points into account the Committee is of the view that a referral to the Secretary of State is unlikely to be successful.

5.7. In response to the continued concerns of Hampshire stakeholders the HOSC reaffirms its view that these changes have not been demonstrated to be in the interests of the Hampshire residents that will be affected. It therefore recommends that :

_ Surrey and Borders NHS Trust establishes a steering group comprising of local stakeholders to oversee the implementation of the planned changes in Hampshire. This group will have a specific remit to look at access to community mental health services, the availability of support with travel costs, the care pathways in place to support service users and the effectiveness of local stakeholder engagement. It will be open to this group to report its findings to the HOSC as it considers appropriate.

_ the feasibility of the contract for inpatient care being provided by another local NHS Trust is explored as part of the review being taken forward by NHS Hampshire and HCC Adult Services This work should be completed before any changes are made to existing provision and reported back to the HOSC.

6. West Sussex PCT: Acute Service Reconfiguration: West Sussex Primary Care Trust - Acute Service Reconfiguration

6.1. West Sussex PCT has confirmed that it is looking at its commissioning intentions for maternity services, in-patient paediatrics and emergency surgery however the timetable for this has slipped yet again.

6.2. It is not yet clear how much stakeholder input is informing this process or how the public will be engaged.

6.3. The PCT Board will decide how it wishes to proceed in November/December and this is likely to be the trigger for reconvening the Joint HOSC.

6.4. It is not clear if this work will impact on health services in Hampshire

Recommendation

6.5. That the Committee be kept appraised of any further developments relating to this work.

7. South Central SHA: Consultation on proposals to fluoridate drinking water in Southampton and South West Hampshire

7.1. The Judicial Review challenge to the SHA has now been given leave to proceed on limited grounds. These are in summary that the Regulations do not appear to give effect to what was apparently stated unequivocally by Ministers to be the position at the time i.e. that fluoridation would only go ahead where the local population was in favour. The Judge has therefore ordered that the Secretary of State for Health should become a party to the proceedings. This means that the Secretary of State will be legally represented at the full hearing and will be asked to explain the apparent differences between what was stated to be government policy and the actual wording of the Regulations.

7.2. Permission to proceed with Judicial Review on the second ground has been refused. The second ground was that the Health Authority did not have regard to the cogency of the arguments advanced for and against fluoridation

7.3. The claimant's solicitors are submitting a renewed application to have the second ground included in the Judicial Review proceedings.

7.4. Other PCTs considering proposals to fluoridate water in their area have put these plans on hold until pending the outcome of these legal proceedings.

7.5. Given this development the Chairman of the HOSC has recommended that the report back to Council on the feasibility of a referendum be deferred until the outcome of the Judicial Review is known.

Recommendation

7.6. Members are briefed on progress with the Judicial Review.

8. South Central SHA: Provision of Primary Angioplasty Services

8.1. The South Central Specialist Commissioning team has alerted the HOSC to the intention to consult on arrangements for providing access to primary angioplasty services in order to improve survival for patients experiencing certain forms of heart attack. NHS Hampshire will be leading the consultation for Hampshire, Portsmouth, Southampton and the Isle of Wight.

8.2. Members from each of the local authority areas affected have already indicated that these changes are likely to be significant and should therefore be subject to formal consultation. This is likely to commence in the New Year.

8.3. An outline of the proposal is attached at Appendix Four

Recommendations

8.4. The Joint Hampshire, Portsmouth Southampton and Isle of Wight HOSC formally scrutinises the proposals for primary angioplasty.

8.5. All Members of the Hampshire HOSC will be provided with an opportunity to share their views on the proposals with the Joint HOSC

IMPACT ASSESSMENTS:

1. Equalities Impact Assessment:

N/A

2. Impact on Crime and Disorder:

N/A

Appendix One

Developing the way in which Mental Health Services are provided in Hampshire

An update for information and consideration by Hampshire Overview and Scrutiny Committee

September 2009

1.0 Purpose

The purpose of this paper is to update the Overview and Scrutiny Committee with regards:

· Progress in developing older people's mental health services in Andover.

· Developments being made to Adult Mental Health Services.

· The potential impact of the Oak Park development issues on service provision.

2.0 Older People's Mental Health Services in Andover

· The Trust and NHS Hampshire worked together to engage the public around Older Peoples Mental Health Services in Andover and in May 2009 members agreed to the implementation of a new model of care. The current position is set out in Appendix 1. All staff received offers of suitable employment with the Trust or secured external employment prior to the changes being made.

· Staff have been appointed to the enhanced community services and three new staff have been appointed to start work during September 2009.

· All patients were discharged from the Unit to their permanent residence and no one transferred to another ward before the Unit closed on 5^th August 2009.

· Agreement has been reached with Winchester and Eastleigh Healthcare NHS Trust and with Neighbour Care which would offer two choices of transport for relatives travelling from Andover to Winchester.

· An Implementation Board has been established to oversee the developments and to ensure that good communications between partners is maintained.

· A further Stakeholder Event is planned for 18^th November 2009.

3.0 Improvements being made to Adult Mental Health Services

3.1 National and local developments

The implementation of the National Service Framework (NSF) for Mental Health in 1999, a ten-year plan to make improvements to services for people with mental health problems, has seen the development of the following services:

· Crisis Resolution and Home Treatment

· Assertive Outreach

· Early Intervention in Psychosis services

· Support Time and Recovery Workers

These improvements in practice have helped more people to have the right treatment at home or another community-based setting, rather than in hospital. There is evidence nationally that suicides have reduced over the last few years. The changes have also helped increase the number of mental health doctors and nurses.

There is a now a new national drive to review the way in which services are provided. The Department of Health consultation document New Horizons: towards a shared vision for mental health was published in July 2009 and consultation continues until 15 October 2009. Hampshire Partnership NHS Foundation Trust will start work with NHS Hampshire and Hampshire County Council later this year to engage a wide range of stakeholders and develop a new strategic direction which will reflect many of the important themes highlighted in this document.

Within the Trust, clinical teams and service user representatives are working to deliver care in ways that maximise social inclusion and recovery within the context of increased personalisation. However, looking at historic practice, the Trust and the Primary Care Trust recognised that some patients have been admitted and maintained in rehabilitation inpatient units and psychiatric intensive care beds for longer than recommended guidelines.

For example some service users in Trust Psychiatric Intensive Care Unit (PICU) facilities have had lengths of stay of more than 90 days and in some cases over 180 days, whereas the Policy Implementation Guide for PICU and low secure provision (2001) published by the Department of Health indicates that length of stay must be appropriate to clinical need and assessment of risk but would ordinarily not exceed eight weeks (56 days) in duration. Indeed the national average length of stay is 26 days (ref: NHS Institute for Innovation and Improvement, Focus on PICUs 2008). Whilst there will always be cases where there are exceptional reasons for longer stays, the Trust is committed to promoting independence and enabling people to be supported in the least restrictive environment that is appropriate to need and assessed risk.

In line with this, the Trust and NHS Hampshire are planning to develop the way in which rehabilitation services are provided and to address practice within the psychiatric intensive care inpatient service. The aim is to strengthen the relationships between inpatient services and other services, particularly crisis resolution and home treatment teams, and ensure the pathway is clearer. This will ensure patients receive the right treatment at the right time, and will receive assessment and treatment from the right professional in the right environment. Through this we expect to continue to improve outcomes for people with mental health needs.

3.2 Financial context

The national economic climate has heightened the need for the NHS to ensure that cost as well as clinical effectiveness is achieved in the delivery of services. The developments in service set out above are in line with clinical trends and best practice guidance and will also help to ensure that best use is made of all our resources - staff and buildings as well as money. The Trust has an obligation to continuously improve the value for money of services and this provides a further driver for the proposals that the Trust is making.

3.3 Rehabilitation

The current service model of 105 inpatient rehabilitation beds across eight units is under review. A number of rehabilitation units were established following the closure of the larger mental health hospital centres of the past. Significant work has been undertaken to develop recovery focussed, faster-stream rehabilitation across a number of units. Many service users who had been in the units for long periods of time have now been transferred to other settings in partnership with other health and social care agencies. The Trust acknowledges the support of NHS Hampshire and Hampshire County Council as partners in this work, which is ongoing and includes development of robust support for service users including benefits, housing and employment services.

As a result of these trends, Rivendale rehabilitation unit based on the Coldeast site in Fareham is underutilised and the Trust and NHS Hampshire have care plans in place for the remaining patients to be discharged in the coming weeks. The model of care has shifted to promote different pathways into independent living. The Trust is of the view that capacity across the Trust exists to absorb the needs of clients and it is proposed to close these beds. The Trust is also proposing to review the way in which rehabilitation services are provided in Crowlin House in Southampton, in which NHS Hampshire currently contracts two beds for Hampshire residents. The Trust is of the view that these beds are also likely to cease to be required once individual care plans are implemented. This would leave the Trust with 73 rehabilitation beds, in addition to 169 acute inpatient adult mental health beds.

3.4 Psychiatric intensive care

Psychiatric intensive care is for patients compulsorily detained under the Mental Health Act who are in an acutely disturbed phase of a serious mental disorder. It is usually provided in a secure environment, to support people whose illness has caused a loss of capacity for self control. The corresponding increase in risk does not enable their safe, therapeutic management and treatment in an open acute ward. Admission to a PICU provides intensive short term intervention to lessen and mitigate risks and treat the individual in relation to their illness.

The service has updated its PICU operational policy and strengthened its PICU bed management process so that the patient's progress between admission and discharge is under continuous review. This is part of improvement work to deliver a more integrated service along the whole care pathway which will ensure patients receive the most appropriate care and have shorter lengths of stay. NHS Hampshire is working with the Trust to ensure that patients who require a secure environment for a longer period of time are transferred to a more appropriate care setting. The outcome of this work is that fewer beds are required in the PICU service.

The Trust proposes to close the 6 beds at Ellingham Ward at Woodhaven Hospital in the New Forest. There have been an average of 4.5 beds used for the population of New Forest and Eastleigh in the two years from April 2007 to March 2009 and these have included a small number of very long stay individuals some of whom required a specialist placement. There have also been a growing number of vacancies across the Trust's PICU beds as a result of changing clinical practice. Hence there is adequate capacity in the remaining PICUs to care for patients requiring this level of care.

Ellingham is the smallest PICU in the Trust, in an area of lowest catchment population and the unit does not have the same level of facilities as other units in managing police admissions. People living in the New Forest will be able to go into the PICU in Southampton to avoid undue travel although in some cases may need to travel to Basingstoke or Fareham as happens now.

3.5 Staff engagement

The Trust has an excellent track record of redeploying staff when needs dictate. The Trust has undertaken a staff consultation exercise within the Adult Mental Health service. This began on 22 June 2009 and concluded on 14 September 2009. Meetings have taken place with individuals and they have been advised they would, if the developments go ahead, be eligible for redeployment. It was agreed in the light of this that vacancies would be put on hold organisation-wide, until the decisions in relation to the proposals which are the subject of this paper be made. At the time of writing this paper, the Trust was not in a position to report the findings and outcomes from the staff consultation but will be in a position to do so when the Overview and Scrutiny Committee meets on 29 September 2009.

The Trust is very mindful of the absolute priority to ensure continuing quality of care and safety in managing any developments in services and to ensure safe staffing levels within these services and more widely across other adult services within the Trust.

3.6 Wider engagement

The Trust has been engaging with users and carers to seek views on future service delivery and what is important to people experiencing services in the way we move forward. There are two days planned for pulling together this feedback in October 2009 and these events will be jointly facilitated with NHS Hampshire. In addition governors of the Foundation Trust are joining the two events in October and working alongside service users and carers as well as members to ensure that the future planning of services reflects this feedback. We will also be involving voluntary organisations as well as other partners. As highlighted earlier in the paper these events rather than `one offs' will mark the start of an ongoing and wider series of discussions about the future of mental health services across the local area in the light of `New Horizons' and national and local plans and strategies.

4.0 Oak Park

The Trust is now aware that some uncertainty exists in relation to the future development of plans for Oak Park. This development had been planned to enable the complete re-provision for Hampshire residents of inpatient services for older people with mental health needs from the St James Hospital site in Portsmouth. The Trust is now giving consideration to the implications of any deferral of the planned Oak Park development, working closely with NHS Hampshire. The Trust proposes to update the HOSC at a future meeting, subject to the plans for Oak Park being clarified.

5.0 Summary

This paper updates the HOSC on a range of important developments and plans for local mental health services, as well as on current engagement programmes with services users, carers and staff and wider engagement with partners.

6.0 Recommendations

The Trust would welcome comments from the HOSC on any of the issues highlighted in the paper together with comments and advice on future engagement plans.

Appendix 1

Hampshire Partnership NHS Foundation Trust

Update to Hampshire Overview and Scrutiny Committee

Older Peoples Mental Health Services in Andover

(September 2009)

1.0 Purpose

1.1 In February 2009 NHS Hampshire and Hampshire Partnership NHS Trust (now NHS Foundation Trust, HPFT) provided a presentation to the Hampshire Overview and Scrutiny Committee (HOSC) about the patient and public engagement work on the development of services for older people with mental health needs in Andover.

1.2 In May 2009, following stakeholder engagement, Hampshire Partnership NHS Foundation Trust and NHS Hampshire presented a proposed model of care for services within the Andover area. This model of care was approved by the HOSC and both Trust Boards

1.3 This paper provides an update regarding implementation of the Andover model.

2.0 Andover Model

2.1 The Andover model consists of 6 key elements:

2.2 Early Diagnosis - provision of memory services and enhanced working with primary care through the Community Innovation Team.

2.3 Improved support in the community - providing enhanced community led services which work in partnership with statutory and voluntary organisations.

2.4 Admission to specialist mental health beds - patients who needs cannot be met by an enhanced community team will be admitted to specialist mental health inpatient units at Melbury Lodge in Winchester or Parklands Hospital in Basingstoke.

2.5 Improved Intermediate care - provide specialist medical advice into Kingfisher Ward, an older persons ward at the Andover War Memorial Hospital, provided by Winchester and Eastleigh Healthcare Trust.

2.6 Improved care in nursing and residential homes - specialist mental health input to care and nursing homes within the Andover area.

2.7 Improved end of life care - working in partnership with other agencies leading to a new service specification for inclusion in commissioning contracts with nursing homes.

2.8 Future developments - working with dementia advisors to improve signposting and support for patients and carers

3.0 Implementation of the new service in Andover

3.1 Staff - Hampshire Partnership NHS Foundation Trust recognised the wealth of skill and experience of the multidisciplinary team and has worked closely with all affected individuals to ensure that staff received offers of suitable alternative employment with the Trust or had secured external employment prior to the Trust offer.

3.2 Patients / Service Users - Trust staff worked with patients and their relatives who were admitted to the Allan Gardiner Unit at the Andove War Memorial Hospital to explain the new model and how their relative would be cared for. All patients were discharged from the Allan Gardiner Unit to their permanent residence before the closure of the Allan Gardiner Ward. No patients were transferred to other wards.

3.3 Allan Gardiner Ward - The ward successfully closed on the 5^th August 2009 slightly ahead of schedule. The reason for the early closure was that from the 3^rd of August the ward no longer had any inpatients in residence. Additionally due to the lack of patients, staff had requested earlier redeployment to their new place of work.

3.4 Community Services - Nurse and Support Worker Resources - Increased qualified and unqualified community team posts were established in July 2008 to enable improvements to community services and the overall care pathway.

3.5 Community Services - Specialist Nurse Advisor (Nursing Homes) - The post has been appointed to in August with anticipated start date in September 2009.

3.6 Community Service - Memory Nurse - The post was appointed to in August and has an anticipated start date in September 2009. The memory service will have close links to the dementia advisor provided through Andover MIND.

3.7 Community Service - Intensive Home Support Service - The post of Nurse Co-ordinator was appointed to in August with an anticipated start date in September 2009. The posts of Support Worker in working hours and Support Worker Out-of-Hours will be advertised in September 2009.

3.8 Community Service - Therapies - Dedicated therapy staff have commenced sessions for service users with organic (dementia type) mental health needs and for service users with functional mental health needs in Andover. Each type of therapy is offered one day a week. A therapy reference group will meet in September 2009. The group consists of health, adult services, carers, voluntary sector and other stakeholders. The therapies group will be asked to become the overarching patient/carer reference group with regards the Andover Model.

3.9 Specialist Mental Health Advice - Increased medical support to the Andover War Memorial Hospital older persons general ward (Kingfisher) through Speciality Psychiatric Doctor.

3.10 Releasing Clinical Time to Care - An additional administrative support post out will be advertised in September 2009. This will reduce the administrative burden on clinicians.

3.11 Transport - For those carers who are unable to travel to Winchester, agreement has been reached with Winchester and Eastleigh Healthcare Trust and with Neighbour Care (Adult Services) to would offer 2 choices of transport options. It is anticipated that this will start in October 2009. Community staff are working with individual carers to assess transport needs and requirements should an Andover patient be admitted to Winchester prior to October 2009. The inpatient ward in Winchester has also adopted flexible visiting hours to support carers who have needs outside of the current visiting times.

3.12 Implementation Board - The implementation board has met twice since July 2009 to ensure that implementation is completed in partnership and that communication between all partners is maintained. The next implementation board meeting is in October 2009.

3.13 Service Information Leaflets - All service leaflets have been reviewed and are currently with the creative services department awaiting final drafting and design.

3.14 Stakeholder Event - A further Stakeholder Event is planned for November 2009.

Appendix Two

Appendix Three: Surrey and Borders NHS Trust response to Hampshire HOSC-

Re: Our Future Your Say for Hospital Services Consultation

We appreciate the continued interest and oversight of our plans for developing new and improved hospital facilities for the people of Surrey and North East Hampshire by the Hampshire Health Overview and Scrutiny Committee.

As you are aware our joint consultation, led by NHS Surrey, concluded on 31^st March 2009 and we last spoke with the Committee regarding the plans on this date.

We have noted the comments made in your letter of the 3^rd April 2009 and are pleased that it is recognised that the modernisation of inpatient mental health services is necessary. We also take seriously your concerns that further work is needed with Hampshire stakeholders.

Our Trust Board met on 29^th July to consider everyone's the feedback and NHS Surrey Board will meet in public on 8^th September for their deliberations. We therefore wish to bring you up to date with our decisions on the way forward and explain how we intend to address your ongoing concerns.

NHS Surrey and our Trust received an unprecedented level of response from our community and overwhelming support for the long overdue investment to improve our hospital services. The feedback received has been independently evaluated by The Evidence Centre on our behalf and a copy of their report is attached for your information together with our joint response to each of the themed areas of feedback.

The Surrey and Borders Partnership NHS Foundation Trust Board has considered carefully all of the feedback and we have decided that the creation of three hospital units will offer the best balance between clinical quality through critical mass, accessibility and affordability. Through the consultation we have heard very clearly the understandable concerns that some communities have regarding the difficult decision about where these three facilities should be located. Our view is that the proposed locations of Guildford, Chertsey and Redhill remain the best options for the majority of people.

NHS Surrey will independently consider the feedback and at their Board meeting and we will work closely with them following their decision on the chosen sites.

To achieve our planned improvements the number of our inpatient units must be reduced. We know that for some of the relatively small number of people who need to receive assessment and treatment in hospital and their families, carers and friends it will mean greater distances to travel when this happens. Having listened to concerns raised regarding this impact, and other feedback from the consultation process, we will be taking forward further pieces of work alongside the development of plans for the new hospitals.

We have discussed with Hampshire County Council and NHS Hampshire the concerns raise by your Committee and have agreed the following to achieve local resolution:

Community Services - During our discussions with communities we have emphasised that the majority of our services are delivered through our network of community services. These are locally based in each borough and will continue to be. However, Hampshire County Council and NHS Hampshire have agreed to undertake a joint review of community mental health services in North East Hampshire to ensure services meet the needs of the local communities and access and equity is assured. This will give us the opportunity to make certain that we optimise the community facilities already available in North East Hampshire including our rehabilitation and recovery 24/7 unit in Farnborough to minimise the need for people to be admitted to hospital.

Additionally, we want to involve communities in helping us to develop our model of community services that bring together resources across care groups to ensure people receive the best assessment and treatment based on their needs and not, for example, their age or diagnosis.

Transport - We have listened to people's concerns particularly regarding the cost and accessibility of transport links and we are committed to working closely with communities, using the transport analysis we have undertaken, to find ways of minimising this impact upon people. For people who use services living in areas that are significantly disadvantaged, such as some areas of Hart, and who do not have their own means to travel to hospital we will develop a travel scheme to help ease this issue. This is one of the key areas of our work with communities and commissioners during the next stage of making our plans a reality.

Care Pathways - Some people have expressed the ability to choose which of the three hospitals they could be admitted to irrespective of the defined catchment areas suggested in the consultation. For example some people in Surrey Heath have expressed a desire to be treated in Guildford as they view it as more accessible to them than Chertsey. We will work carefully during this next stage to refine the care pathways for each of the hospitals to take into account the need to enable choice whilst maintaining safety and clinical continuity.

Further work with stakeholders: We want to assure you that we will work closely with stakeholders during this next phase. We already have a meeting set up with Hart District Council in September and are writing to other key parties such as GPs and local patient groups so that we can meet and discuss this outcome with them. We are committed to ensuring that the community services review involves people who use services and their families. Furthermore until this work is completed we plan to retain hospital services at the Ridgewood Centre.

We would be very happy to have the opportunity to meet with you regarding the decisions we have made and would be pleased to receive your advice on how you would wish to be assured about our continued involvement and engagement of our communities to ensure the benefits of the changes are secured for the people of North East Hampshire.

Thank you for your continued interest in improvements to the experiences of people with mental ill health and learning disabilities across North East Hampshire.

Appendix Four

NHS HAMPSHIRE

DELIVERING AN IMPROVED PRIMARY PERCUTANEOUS CORONARY INTERVENTION SERVICE [PPCI] FOR THE POPULATION OF HAMPSHIRE

1. INTRODUCTION

1.1. This paper has been drafted to provide the Hampshire Overview and Scrutiny Committee with an overview of the way in which NHS Hampshire intends to work with local people and stakeholders to develop and improve the existing provision of primary percutaneous coronary intervention [PPCI] in Hampshire.

2. BACKGROUND

2.1. In October 2008, the Government suggested a rapid expansion of coronary angioplasty (Primary Percutaneous Coronary Intervention or PPCI) for the treatment of heart attack patients in England. Prior to this date NHS Hampshire had established a steering group to look at the provision of Acute Coronary Syndrome patients across Hampshire.

2.2. Evidence suggests that patients who have suffered a heart attack have a greater chance of survival and recovery if they are treated in a specialist centre that provides primary percutaneous coronary intervention (PPCI).

`SHA visions have sent a powerful message that the most effective treatments should be available for all NHS patients. Their plans for transforming treatment for heart attacks vividly illustrate this' (Darzi A (2008) High Quality Care for All)

2.3. The final report of the National Infarct Angioplasty Project (NIAP) was published on 20th October 2008. NIAP was an observational study to test the feasibility of establishing coronary angioplasty (PPCI) as the initial treatment (in place of thrombolysis) for heart attack patients across England. The key findings of the NIAP study were as follows:

· PPCI can be delivered within acceptable treatment times in a variety of settings;

· direct admission to a cardiac catheter laboratory is the preferred route of admission to achieve timely treatment. This shifts the onus of diagnosis onto the ambulance service and away from Accident and Emergency departments.

3. ACUTE CORONARY SYNDROME

3.1. Essentially people with an acute coronary syndrome (heart attack) are divided into two main groups:

Patients with non-ST elevation acute coronary syndrome (NSTEACS)

3.2. These patients are admitted acutely through an Accident and Emergency department into a cardiology (or sometimes general medical) ward. They are treated initially with anti-platelet, anticoagulant and anti-anginal drugs. If they have raised cardiac markers (e.g. troponin), or ongoing symptoms, indicating that they are at high risk of further events, they will usually undergo angiography and be considered for revascularisation, in the form of either PCI or coronary artery bypass graft (CABG). If they have been admitted to a hospital with on-site PCI, the angiogram and PCI will be carried out as a single procedure.

3.3. If admitted to a hospital without onsite PCI, the angiogram may be carried out at the admitting hospital with onward referral to the PCI centre. Alternatively, patients may be transferred to the PCI centre for an angiogram with follow-on PCI if required. Current clinical guidelines suggest that PCI should be performed within 72 hours of admission. NSTEACS patients occasionally require immediate access to a cardiac catheter lab because of haemodynamic instability, ongoing ischaemia or other co-morbidities, but most can be treated during daylight hours.

3.4. These services should and are available in most General Hospitals

Patients with ST segment elevation myocardial infarction (STEMI)

3.5. Immediate PCI is now the preferred treatment (over thrombolysis) for patients presenting with ST segment elevation MI (STEMI) provided it can be delivered within an appropriate timeframe. These patients are taken directly to the PCI centre for primary PCI. This should be performed as soon as possible and preferably within 120 minutes of the patient first summoning medical help. Primary PCI, therefore, mandates 24 hour access to the cardiac catheter lab.

4. NHS HAMPSHIRE APPROACH

4.1. Across South Central, Primary Care Trusts are working with the Cardiac Network to develop improvements in the provision of PPCI, in line with the national steer.

4.2. NHS Hampshire has established a Steering Group charged with developing its approach to PPCI. The Hampshire PPCI Steering Group is chaired by Dr David Balfour of NHS Hampshire and draws representation from a wide range of clinical interests.

4.3. Whilst this paper is focused on the way forward for Hampshire, there have been very positive discussions with partners in Portsmouth, Southampton and the Isle of Wight about taking forward the approach, identified below, collaboratively. This will be confirmed in the next fortnight.

4.4. From its inception, the approach of the Steering Group, in line with recommendations from the Royal College of Physicians, NIAP, NICE, and NHS improvement, was to put forward a case that there should be 24 hour access to PPCI for all its patients.

4.5. The Steering Group felt strongly that patients should not suffer significant risk because their event occurred out of hours or at weekends. Evidence shows clearly that there is a 50% increase in mortality in patients having traditional thrombolysis over those receiving timely PPCI.

4.6. The steering group has therefore drawn up a draft service specification for the delivery of PPCI (see Appendix A). This specifies what good practice looks like and, if implemented, would guarantee equity of access and care for all Hampshire residents.

4.7. It does not dictate which Hospitals should or should not provide the service, although it is likely that some of NHS Hampshire's providers could struggle to meet what are essentially nationally agreed evidence based standards.

5. COMMISSIONING IMPLICATIONS

5.1. In some ways, commissioning of a PPCI service differs from the commissioning of other new clinical services. The procedure (PCI) is already commissioned. Initial fears that commissioning a PPCI service might lead to a substantial growth in total PCI numbers have been unfounded. In West Yorkshire, the introduction and roll-out of PPCI to a population of around three million has led to no increase in absolute PCI numbers, even though PPCI now makes up 30% of the total PCI procedures. The reason for this is clear: when thrombolysis was the standard treatment for STEMI patients, around 60-70% of thrombolysed patients underwent angiography and/or PCI within six months of their initial presentation. Therefore, a policy of PPCI brings forward the PCI procedure to the time when the patient has the most to gain.

6. PROPOSED WAY FORWARD

6.1. The next phase of the development will be to work with the local community, service users and carers in the development and commissioning of an appropriate PPCI service across Hampshire.

6.2. The key audiences for this phase will be:

· Staff

· Public

· Service users

· Carers

· Local clinicians

· Local politicians

· Local voluntary and community groups

· Media

Objectives

6.3. The objectives of this phase of the process will be to:

· listen to the views of services users and their carers and ensure and develop a service specification which reflects their views;

· involve local service users, carers in the commissioning of local services to deliver this specification;

· inform and involve local NHS staff, local partner organisations and the local community in the development of a PPCI service specification and the commissioning of a local service to deliver this specification;

· provide accurate and timely information on the current and future plans for the delivery of PPCI across the county.

Methods of communication and engagement

· Face to face: staff and stakeholder meetings, discussion and briefings

· Publications: targeted bulletins; staff newsletters; community groups', charitable organisations', local authority and parish magazines

· Media: print and broadcast media via media releases and interviews

· Opinion research: targeted research into service user and carer views

· Web: NHS Trust websites, Community Voices online, partner websites

Approach

6.4. It is anticipated that three main approaches will be used during this phase:

a) to proactively undertake opinion research into service user and carer views to inform the service specification

b) to undertake face to face briefings and discussion with interested parties by mapping existing meetings and key contacts and proactively attending stakeholder meetings to listen and respond to local views

c) to develop greater interaction with, and information for, local community groups, voluntary organisations, service user/carer groups and faith groups in order to listen and respond to local views.

Tactics, implementation and measurement

6.5. The outline implementation plan is set out at Appendix B

7. OUTCOME

7.1. Following this period of involvement, it is anticipated that NHS Hampshire will have finalised a PPCI service specification for subsequent implementation. An update on this work will be presented, if required, to the HOSC in November 2009. The Steering Group will be broadened to ensure service user / carer representation as the specification moves forward for implementation.

7.2. In the light of the challenge that some providers may face in meeting the proposed quality standards, NHS Hampshire and the Steering Group will continue to work with the HOSC around the next steps.

APPENDIX A

SERVICE REQUIREMENTS 1

General

· Minimum of 400 PCI procedures per annum

· Minimum of 75 PCI procedures per operator

· Minimum of 2 cardiac catheterisation laboratories (see below)

· Cath lab available to reopen for minimum of 6 hours post procedure

PPCI Specific

· In the first year a minimum of 50 PPCI procedures per annum, working towards a target of 80 PPCI¹.

SERVICE REQUIREMENTS 2:

· Provide 24/7 PPCI service (in house or agreed networked solution) throughout year

· PPCI patients to be admitted directly to cath lab or cath lab reception area (bypassing A&E)

· Achieve Care Quality Commission targets. Initial target of call to reperfusion time of 150mins in 75% of patients

· Target of call to reperfusion time of 120mins achieved in 75% of cases irrespective of time of day/night (NHS Hants target)

SERVICE REQUIREMENT 3:

· Must have a defined clinical lead

· Must submit complete validated data electronically to MINAP and BCIS datasets

· Must achieve all PCI related Care Quality Commission standards

· Must agree, measure and report against a set of quality and patient experience metrics

SERVICE REQUIREMENT 4:

Service Specific

· Facility for Ambulance service to pre-alert staff of patient arrival at all times

· Cardiology staff to manage patient throughout hospital stay from point of entry

· Sufficient cardiology staff with European Working Time Directive compliant rota to support a service 24/7 including holiday cover

· Emergency cath lab available for PPCI at all times within the time frame for PPCI - either within provider or within network

· Door to balloon times of <90mins in 75% of patients

· Door to balloon times of <60mins in 50% of patients

· Facility for Intra Aortic Balloon Pumping and Temporary Pacing at all times

· Dedicated cardiac care beds for PPCI patients

· Availability of echocardiography 24/7 in all centres

· Integrated Care Pathway for PPCI patients with expected date of discharge <72 hours post PPCI

· Multi-vessel disease - Revascularisation of all culprit lesions on same admission in >90% of cases

· Discharge medication

o Aspirin >95%

o ACE I, β-blocker, statin, Clopidogrel, all >90%

· Final discharge information to Primary Care within 24 hours of discharge in 100% of cases

· Provision of phase 1 cardiac rehabilitation in all patients at PPCI centre

· Link to and transfer of information at discharge to providers of phase 2 & 3 cardiac rehabilitation

SERVICE REQUIREMENT 5:

Annual 30-day mortality for PPCI >8% triggers service review by British Cardiovascular Intervention Society on behalf of NHS Hants

SERVICE REQUIREMENT 6:

· Full cover between the hours of 8am and 6pm Monday to Friday excluding Bank Holidays (it is further suggested that non 24/7 units should have staff available to accept calls from 7.30 a.m. so that the catheter lab can be prepared for a patient arriving at 8.00 a.m.)

· Receipt of a call from SCAS at 17:59 reporting a STEMI patient en route activates the cath lab, without exception

· The service will run every week of the year and include cover for staff holidays

· The ability to deliver this will be evidenced by:

o Written submission of proposed cath lab staffing levels

o Written submissions of consultant job plans

o Written submissions of arrangements for holiday cover

o Audit by the network in collaboration the SCAS

· Daytimes centres must commit to reopening the cath lab for up to 6 hours post PPCI to deal with any daytime procedures that subsequently need further attention

Appendix B

PPCI OUTLINE IMPLEMENTATION PLAN