Oli Hudson, of Wilmington Healthcare, explores the NHS’s bid to split urgent and planned care into separate sites and redesign specialist services.

Introduction

The NHS Long Term Plan’s promise to continue backing hospitals that wish to separate urgent and planned care into different sites will bring significant changes to medtech’s customer base.

This style of working is already happening in some areas where urgent and planned services have been divided into what are known respectively as ‘hot’ and ‘cold’ sites in a bid to improve surgical services.

There are also moves to reconfigure specialist care in order to improve patient outcomes and service efficiency, and deliver more services in integrated community settings, closer to patients’ homes.

‘Hot’ and ‘cold’ sites

The Long Term Plan explains that by providing planned services from a ‘cold’ site, capacity for these services can be protected to reduce the risk of operations being postponed at the last minute due to more urgent admissions.

Meanwhile, the plan says that “managing complex, urgent care on a separate ‘hot’ site allows trusts to provide improved trauma assessment and better access to specialist care, so that patients have better access to the right expertise at the right time.”

However, the plan acknowledges that it would not be possible to achieve this split in all areas and says it would also introduce a new option of ‘A and E locals.’

Support from GIRFT

It is difficult to predict how ‘hot’ and ‘cold’ services will evolve across England until all local health systems have published their operating plans, as required under the Long Term Plan. This is expected to happen by the autumn.

However, Getting It Right First Time (GIRFT), which aims to improve patient care by reducing unwarranted variation in expenditure and efficiency across NHS trusts, is already piloting ‘hot’ and ‘cold’ sites for trauma and orthopaedics in a number of hospital trusts across the country.

As part of this, Professor Tim Briggs, GIRFT chair, formally opened new side rooms at St Michael’s Hospital in Hayle in January. The Royal Cornwall Hospitals NHS Trust has transferred its planned in-patient orthopaedic surgery to Hayle and the changes have released capacity at the Royal Cornwall Hospital for emergency patients. Since the pilot began, the trust said it had reduced the number of patients waiting more than 12 months, down from 130 in April 2018 to 38 in December 2018, with the expectation of achieving zero by the end of March this year.

The move followed an announcement in November 2018, that University Hospitals Plymouth (UHP) would be a pioneer in establishing a hot/cold site split of its emergency and elective orthopaedic service whilst maintaining services to both regional major trauma and local trauma patients. This was part of a raft of changes to be piloted in the area.

In the east of the country, it was recently announced that United Lincolnshire Hospitals NHS Trust (ULHT) had moved to split site working for trauma and orthopaedic (T&O) surgery, following a successful six-month trial.

Gloucestershire

Gloucestershire Hospitals NHS Foundation Trust is cited as a case study in the NHS Long Term Plan, which explains how GIRFT helped the trust to split its ‘hot’ emergency work and ‘cold’ planned trauma and orthopaedics work into two separate sites. Senior clinical decision makers were also introduced at the A&E ‘front door’ to help ensure patients were managed more effectively.

The Long Term Plan says that “during the first six months, the trust was able to achieve its four-hour A&E target for the first time since 2010 and had halved the number of cancelled operations. There was a reduction in waiting times for surgeries, including for hip or knee replacements, and an 8% increase in the amount of elective surgery performed.”

Shropshire, Telford and Wrekin STP

In January, the Joint Committee of Shropshire Clinical Commissioning Group (CCG) and Telford and Wrekin CCGs approved a major reconfiguration of the trust. The new plans were put forward under the NHS Future Fit scheme – a four-year project led by the CCGs to review service provision at The Shrewsbury and Telford Hospital NHS Trust.

The CCGs decided to install a dedicated planned care site at the Princess Royal Hospital (PRH) in Telford, while the Royal Shrewsbury Hospital (RSH) will become a specialist emergency care site.

Cheshire and Merseyside

In Cheshire and Merseyside, some specialist services have been reconfigured to improve patient recovery times and outcomes. For example, a new hyper acute rehabilitation ward at The Walton Centre now treats patients at a much earlier stage following a traumatic head injury. A new network team co-ordinates a staged pathway of care which includes specialised rehabilitation at Walton and in three ‘spoke’ hospitals and in community settings.

The Liverpool Heart and Chest Hospital has changed the service delivery model for emergency surgery on acute Type A aortic dissection with all elective and emergency aortic surgery being carried out by three surgeons sub-specialising in aortic surgery. The effect on surgical outcomes is reported as dramatic with current mortality rates at less than 10%, compared to a rate of 22.8% across Britain.

Conclusion

As the NHS pushes for urgent and planned work to be delivered on different sites and trusts come under pressure to drive improvements in specialist care, we expect to see significant service reconfiguration across England.

Medtech needs to understand how pathways are already being redeveloped in some parts of the country and keep abreast of further changes that will be happening elsewhere, as local health economies respond to the Long Term Plan’s vision for the future.