Case for Change (published July 2021)

Section 7: Delivering the Lancashire and South Cumbria Clinical Strategy

The New Hospitals Programme sits within the wider transformation of Lancashire and South Cumbria’s integrated care system and is a long term enabler to delivering the Healthier Lancashire and South Cumbria vision. There is a system-wide recognition of the need to work differently to achieve clinically sustainable services across primary and community care, urgent and emergency care, hospitals and specialist care to improve outcomes for the people of Lancashire and South Cumbria.

There are higher than expected levels of emergency admissions in the region, compared to the national average. Residents are 12% more likely to be admitted for all causes, 28% more likely for coronary heart disease and 27% more likely for Chronic Obstructive Pulmonary Disease (COPD). Mortality rates (for under 75s) is greater for 50% of counties in Lancashire and South Cumbria compared to the North West region average (388 per 100,000).

The integrated care system’s Clinical Strategy has set out three principle aims:

1. Improving health and wellbeing
2. Delivering better joined up care closer to home
3. Safe, sustainable high-quality services.

The Lancashire and South Cumbria Clinical Strategy (opens in a new window) outlines its priorities in response to the NHS Long Term Plan (opens in new window) and the future health needs of our population across six key programme areas shown in Figure 15.

Figure 15: Clinical strategy priorities (highest priority integrated pathways for improvement are indicated with **)

The New Hospitals Programme will support the long term future development of our clinical priorities, including single shared services or specialty networks, which will be based on:

A single service approach across Lancashire and Cumbria, delivered from a specialised hub and with outreach across the network to provide care locally where possible

Or

Services provided from one central site as part of a single service offer for Lancashire and South Cumbria, in order to meet the volumes and co-location required to meet national standards

Or

Single service offers achieving standards across more than one site.

The Lancashire and South Cumbria Provider Collaborative is already transforming services and exploring the benefits to patients and staff of networks and greater collaboration. Our Major Trauma Network has facilitated significant improvements to access and sustainability of these services.

Further work is taking place to inform our long-term clinical services strategy. Some of these plans may require engagement and / or consultation.

“These are complex and ambitious plans and we need to look beyond individual organisations to consider the structure of services across the whole system.”

Specialised services

The Lancashire and South Cumbria Provider Collaborative is already transforming services and exploring the benefits to patients and staff of networks and greater collaboration. Our Major Trauma Network has facilitated significant improvements to access and sustainability of these services.

Further work is taking place to inform our long-term clinical services strategy. Some of these plans may require engagement and / or consultation.

Specialised services in Lancashire and South Cumbria

While some specialised services can only be delivered at a national or cross-Lancashire and South Cumbria level, some of our patients travel long distances to access care when:

(i)  We could expand choice for patients by providing services closer to home, where there is the expertise, volumes and ability to deliver outcomes in line with national standards.

(ii)  There could be opportunities for further specialist services to be provided in Lancashire and South Cumbria, where they have historically been provided elsewhere. Further work is required to understand this, but potentially some services in cardiac, neurosciences and haematology could be provided in Lancashire and South Cumbria. For example, in cardiology, there are out of area flows for Implantable Cardioverter Defibrillator (ICD) and Electrophysiology services.

Achieving this will require consideration of the models of care. Tier 1 specialised services account for around 7% (around £32m) of the total and typically could be delivered in region.

We cannot achieve this with our current infrastructure because we do not have:

• The capacity for specialised and support services, including the associated workforce. We have previously outlined how specialised services have expanded at Royal Preston Hospital over time without the required physical space.
• The flexible capacity to accommodate services that are changing with rapidly advancing technology.
• Single room capacity to ensure the highest standards of infection control, in particular for cancer patients.
• The required capability to accommodate advances in digital technology to support care closer to home and networked hospital solutions.

How our estate impacts on the quality of clinical care and our patients’ experience

Patients wait longer for treatment than is acceptable because of the lack of capacity in and flexibility of our estate. We are below the national average position on several key performance standards:

In their recent study of NHS hospital build programmes, the Nuffield Trust found significant evidence that better infrastructure and, in particular, access to a view led to quicker recovery time for the patient.

“More could have been done to incorporate well-evidenced lessons about how design can minimise noise, reduce stress, improve the staff working environment and improve outcomes and experience for patients.”

Source: Edwards, N. Covid-19: lessons for hospital building programmes (2020). Nuffield Trust (opens in new window).

Royal Lancaster Infirmary’s Emergency Department was built for a predicted capacity of 40,000 patient attendances per year, with actual attendances at around 60,000. Furness General Hospital’s Emergency Department has an annual capacity of 25,000, but actual attendances are around 36,000. This means patients remain on corridors or in crowded waiting areas, with significant delays to admission or treatment and an added infection risk.

Royal Preston Hospital has a cancellation rate of 4%, well over the national average of 1%. 20% of patients in LTHTr were not treated within 28 days of a cancellation, twice as high as the national average of 9%. Figure 17 below shows the reasons for cancellations, with over 70% attributable to capacity or equipment. Central Lancashire has been the most challenged area for Delayed Transfers of Care (DTOC) across the Lancashire footprint, with 7.28% for LTHTr.

Figure 17: Reason for cancelled operations at LTHTr – 70% of cancellations are due to bed capacity or equipment

• No bed on ward: 839 (55%)
• Overrun: complication with previous patient: 174 (11%)
• Overrun: emergency admission: 134 (9%)
• No equipment / equipment failure: 97 (6%)
• No surgeon: 77 (5%)
• No Intensive Care Unit / High Dependency Unit bed: 57 (4%)
• No theatre staff: 54 (4%)
• Overrun: list overbooked: 20 (1%)
• Overrun: late start: 18 (1%)
• Other non-clinical reason: 17 (1%)
• Administrative error: 16 (1%)
• No notes / no results: 8 (1%)
• No anaesthetist: 6 (0%)

Bed occupancy rates

Bed occupancy rates are 95%; above the 85% rates recommended by NICE. This creates a critical safety issue at peak times and impacts on our flow.

Separation of electives and non- electives

The separation of planned and elective work is recognised best practice in achieving good flow and maximising patient experience. The current estate does not permit this. UHMBT and LTHTr are progressing plans to deliver Green Sites; however there is a shortfall of funding for Royal Lancaster Infirmary. The lack of separation of planned and non-elective work is a consistent theme across women’s services at the RLI and Furness General Hospital.

Co-location of mental health facilities

We cannot provide an acceptable standard of care for patients with acute mental illness. Across all our Emergency Departments there is insufficient space to provide adequate separation. This is a key issue with attendance from patients in mental health crisis continuing to rise.

Limited single room provision

Limited single room provision and toilet and shower facilities impact on patient experience and increase risk of infection. This is evident in our hospital-acquired infection rates compared to the national average. Our patient experience scores remain good, despite the inadequacy of our facilities. Standards of privacy and dignity have been underscored by women’s and children’s services.

How the New Hospitals Programme will help deliver our clinical strategy

New models of acute care will be needed to deliver the clinical vision for 2030 and the integrated care system clinical services strategy sets an expectation for closer working of providers across Lancashire and South Cumbria to achieve this. Development of new hospital infrastructure will be a key enabler in delivering our long term clinical strategy, improving outcomes and delivering care closer to home for our population.

As system wide plans progress, the expectation is that acute models of care delivery will change and a significant shift left will take place as the focus moves to preventative and out of hospital care. These developments will be vital considerations for the New Hospitals Programme.

Investment in world-class hospital infrastructure around a centre of excellence with leading technology and research facilities will address these shortfalls. Furthermore, and crucially, this will provoke a much needed step-change in Lancashire and South Cumbria as an attractive place to work for the best clinical and research teams in the world.

If we can accommodate the benefits of new digital technologies, we can create a network of care, providing more specialised services in our hospitals and delivering more care close to home as part of the wider ambitions of the Lancashire and South Cumbria Health and Care Partnership.