Learning from the Experience of Service Centralisation in Leeds

Learning from the Experience of Learning from the Experience of Service Centralisation in LeedsService Centralisation in Leeds

Dr Greg ReynoldsDr Greg ReynoldsConsultant CardiologistConsultant Cardiologist

Clinical Director Cardiology and Respiratory Clinical Director Cardiology and Respiratory Medicine Medicine

First consultant appointment 1996, ST14First consultant appointment 1996, ST14

College tutor for 4 years (36 SHOs)College tutor for 4 years (36 SHOs)

Cardiology Training Program Director (31 SpRs) Leeds and Cardiology Training Program Director (31 SpRs) Leeds and Hull based traineesHull based trainees

On call for Cardiology and for Acute Medicine 1:7On call for Cardiology and for Acute Medicine 1:7

Clinical Director for Cardiology (+Respiratory Medicine) since Clinical Director for Cardiology (+Respiratory Medicine) since 20042004

Senior Clinical Leader role (SHA) DarziSenior Clinical Leader role (SHA) Darzi

Choose and Book lead (SHA)Choose and Book lead (SHA)

Joint chair Cardiology Redesign group (from old Long-term Joint chair Cardiology Redesign group (from old Long-term Conditions pathway group) NHS LeedsConditions pathway group) NHS Leeds

Joint chair Public Health steering group NHS LeedsJoint chair Public Health steering group NHS Leeds

Reflection: I am quite good at spending other people’s money

Management style is by agreementCommunity Heart Failure project 2003 £500K PCT expenditure on heart failure serviceCited by Leeds PCT as an example of good practicePublic Health £500K community service development 2010 NHS Leeds, website LeedsLetsChange Cardiac redesign 2011, NHS Leeds commissioned blood testing program (BNP) £120K pa against future savings from the Acute Trust

Leeds HospitalsLeeds Hospitals

Leeds population 850,000Leeds population 850,000Two main teaching HospitalsTwo main teaching Hospitals

Leeds General Infirmary (LGI)Leeds General Infirmary (LGI)older, traditional, central Leeds, close to shops and older, traditional, central Leeds, close to shops and restaurantsrestaurants

St James HospitalSt James Hospitalbuilt on site of Victorian workhouse, built on site of Victorian workhouse, huge bed base, poorer part of the cityhuge bed base, poorer part of the city(LGI expensive cars an opportunity)(LGI expensive cars an opportunity)

United Leeds Teaching HospitalsUnited Leeds Teaching Hospitals

The two Trusts merged in April 1998 The two Trusts merged in April 1998 to become the largest single Hospital Trust to become the largest single Hospital Trust in the UKin the UK

We all agree we are now one organisationWe all agree we are now one organisation

But of course St James (LGI) is better than But of course St James (LGI) is better than LGI (St James) and always will beLGI (St James) and always will be

United Leeds Teaching HospitalsUnited Leeds Teaching Hospitals

This was a merger of Chief Execs and the This was a merger of Chief Execs and the Trust boards in April 1998Trust boards in April 1998

In practice the name on the stationery In practice the name on the stationery changed but little direct effect on serviceschanged but little direct effect on services

Most services still available on both sitesMost services still available on both sites

Became “Leeds Teaching Hospitals”Became “Leeds Teaching Hospitals”

Reflection on Trust merger

Scottish independence ?

Hostile takeover ?

Slap in the face with a wet fish ?

Jubilee BuildingJubilee Building

Opened in late1998Opened in late1998

New building cost £90 millionNew building cost £90 million

Yorkshire Heart Centre built on the LGI siteYorkshire Heart Centre built on the LGI site

(+ neurosurgery)(+ neurosurgery)

In retrospect built on the wrong siteIn retrospect built on the wrong site

Cardiology centralisationCardiology centralisation

A Cardiologist from LGI and a Respiratory A Cardiologist from LGI and a Respiratory Physician from St James were chatting in Physician from St James were chatting in their local pub (Oct 2005)their local pub (Oct 2005)

Wouldn’t it be a good idea if my service Wouldn’t it be a good idea if my service centralised on my site…..centralised on my site…..

And most people agreed this would be a And most people agreed this would be a good ideagood idea

If the idea is right don't let existing cultures If the idea is right don't let existing cultures and prejudices dictate strategyand prejudices dictate strategy

Achieving Clinical Achieving Clinical EngagementEngagement

Achieving Clinical EngagementAchieving Clinical Engagement

LGI “Yorkshire Heart LGI “Yorkshire Heart Centre”Centre”

14 Cardiologists14 Cardiologists

3 Respiratory 3 Respiratory physiciansphysicians

74 Cardiology beds74 Cardiology beds

St JamesSt James

5 Cardiologists5 Cardiologists

6 Respiratory 6 Respiratory PhysiciansPhysicians

56 Cardiology beds56 Cardiology beds

SJUH Consultants viewSJUH Consultants view

But of course St James is better than LGI and But of course St James is better than LGI and always will bealways will be

5 consultants5 consultantsMy predecessor as Clinical DirectorMy predecessor as Clinical DirectorProfessor of CardiologyProfessor of Cardiology3 very competent clinical cardiologists3 very competent clinical cardiologists

This was an entirely competent clinical serviceThis was an entirely competent clinical service

Why change ?

The Trust Board say that patient safety comes first, but we all know that they only reward meeting targets which allow (us) to achieve Foundation Trust status

Was this simply a cost saving exercise ?

SJUH Consultants viewSJUH Consultants view

Following a series of meetings 4 Following a series of meetings 4 consultants accepted the rationale for consultants accepted the rationale for change and were in agreement to work change and were in agreement to work to to achieve the goals of the organisationachieve the goals of the organisation

One did not. A compromise solution was One did not. A compromise solution was agreed with the Medical Director. The agreed with the Medical Director. The consultant has since retired.consultant has since retired.

Achieving Clinical EngagementAchieving Clinical Engagement

Not everyone will agree, need opinion Not everyone will agree, need opinion leaders on board*leaders on board*

Some solutions need high level external Some solutions need high level external pressurepressure

(*The recent clinical engagement day I attended said you (*The recent clinical engagement day I attended said you need complete agreement on why change is needed….) need complete agreement on why change is needed….)

Planning service changePlanning service change


130 Cardiology beds cross-site became 130 Cardiology beds cross-site became 100 beds on a single site100 beds on a single site

Immediate staff concern regarding loss of Immediate staff concern regarding loss of employmentemployment

Continued to provide clinics and a non-Continued to provide clinics and a non-invasive service at St James onlyinvasive service at St James only

Staff groupsStaff groups

DoctorsDoctorsIntricacies of reorganising junior doctor rotas. Intricacies of reorganising junior doctor rotas. More SpRs, less FY1s and SHOsMore SpRs, less FY1s and SHOsNursesNursesClosed one ward on each site with nursing Closed one ward on each site with nursing redeployment very effectively supported by redeployment very effectively supported by matronsmatronsTechniciansTechniciansAgenda for change had recently caused major Agenda for change had recently caused major disruption, no additional lossesdisruption, no additional losses

TimetableTimetable

First discussed Oct 2005First discussed Oct 2005

First meetings Jan 2006First meetings Jan 2006

Ward moves Sep 2006Ward moves Sep 2006

Planning groups, key players including Planning groups, key players including Ambulance serviceAmbulance service

Consultant integration was easier to Consultant integration was easier to achieve than nursing integrationachieve than nursing integration


Staff have a high degree of loyalty to the Staff have a high degree of loyalty to the institutions in which they work and do not welcome institutions in which they work and do not welcome changechange

Once the “tipping point” of accepting the inevitable Once the “tipping point” of accepting the inevitable was reached it became a straightforward planning was reached it became a straightforward planning processprocess

We fully committed to the strategyWe fully committed to the strategy

The year that followed…The year that followed…

The year that followed….The year that followed….

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

The year that followedThe year that followed

Benefits: £3million immediate annual cost Benefits: £3million immediate annual cost saving on a budget of £45 million.saving on a budget of £45 million.

Services delivered efficiently with Services delivered efficiently with economies of scaleeconomies of scale

Consultants able to achieve sub specialist Consultants able to achieve sub specialist ambitionsambitions

Our average length of stay is 5.5 days Our average length of stay is 5.5 days compared to 6.5 days for peerscompared to 6.5 days for peers

None of the consultants would go back to None of the consultants would go back to how it was beforehow it was before

Managers see this as a successful mergerManagers see this as a successful merger

My ward sister preferred her previous My ward sister preferred her previous ward but only since becoming a female ward but only since becoming a female wardward

The year that followed…The year that followed…

Cost savings achieved, quality maintained Cost savings achieved, quality maintained and increased efficiency achievedand increased efficiency achieved

Other Service CentralisationsOther Service Centralisations

Following on from this many further Following on from this many further reorganisations have occurred in Leedsreorganisations have occurred in Leeds

For 10 years a new Children’s Hospital was For 10 years a new Children’s Hospital was projected. projected.

Leeds has struggled for years to balance Leeds has struggled for years to balance the booksthe books

At a cost of £300 million this was deemed At a cost of £300 million this was deemed unaffordableunaffordable

A Children’s Hospital was achieved by A Children’s Hospital was achieved by reconfiguring services in existing reconfiguring services in existing accommodationaccommodation

A major issue for the Children’s Hospital A major issue for the Children’s Hospital has been that obstetric services are on a has been that obstetric services are on a different site requiring the provision of 2 different site requiring the provision of 2 Paediatric ICUs Paediatric ICUs

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

Medicine CentralisationMedicine Centralisation

Leeds has always struggled to achieve Leeds has always struggled to achieve 4 hour access targets4 hour access targets

The success of Respiratory / Cardiology The success of Respiratory / Cardiology centralisation was followed in Medicine centralisation was followed in Medicine division by centralisation of Acute division by centralisation of Acute Medicine and Elderly Medicine at St Medicine and Elderly Medicine at St JamesJames

Same targets: economies of scale, cost Same targets: economies of scale, cost saving, quality and efficiencysaving, quality and efficiency


Medicine centralised in Jan/FebMedicine centralised in Jan/Feb

Elderly Medicine in DecemberElderly Medicine in December

Complete withdrawal of services from LGI site, no Complete withdrawal of services from LGI site, no RMO cover, Failed to look at organisational need, RMO cover, Failed to look at organisational need, too focussed on local service needtoo focussed on local service need

Continuing bed crisesContinuing bed crises

Some care of elderly services housed in old remote Some care of elderly services housed in old remote accommodation with issues about care standardsaccommodation with issues about care standards

Lack of leadership: Insufficient Acute Lack of leadership: Insufficient Acute

Medicine physicians to lead the serviceMedicine physicians to lead the service


Not able to fully integrate neurology and Not able to fully integrate neurology and acute stroke services on alternative siteacute stroke services on alternative site

Don't have the critical mass to deliver Don't have the critical mass to deliver HASU (hyper acute stroke unit)HASU (hyper acute stroke unit)

(Medicine) Centralisation(Medicine) Centralisation

Some services (Medicine, Stroke, Some services (Medicine, Stroke, Children’s services) have struggled Children’s services) have struggled because of split site servicesbecause of split site services

Personal view:Personal view:

It would work better if all services were on It would work better if all services were on one site, if it was affordable I would close one site, if it was affordable I would close my hospital and move to the workhouse sitemy hospital and move to the workhouse site

Finally, Regional Cardiology Finally, Regional Cardiology services and acrimonyservices and acrimony

Since 2006 the gold standard treatment for heart attack Since 2006 the gold standard treatment for heart attack is an urgent angiogram and coronary stent (PPCI)is an urgent angiogram and coronary stent (PPCI)

This requires a consultant cardiologist and cathlab team This requires a consultant cardiologist and cathlab team to be available acutely 24 hours a dayto be available acutely 24 hours a day

Leeds PPCI service covers Leeds, Bradford, York, Leeds PPCI service covers Leeds, Bradford, York, Harrogate, Airedale, Wakefield, Dewsbury and Harrogate, Airedale, Wakefield, Dewsbury and PontefractPontefract

Air ambulance Air ambulance

1000+ cases per year1000+ cases per year

Population ~ 2.5 millionPopulation ~ 2.5 million

Leeds has 7 specialist consultantsLeeds has 7 specialist consultants

Regional CardiologyRegional Cardiology

Agreed that 8 LGI based consultants and 8-12 DGH Agreed that 8 LGI based consultants and 8-12 DGH based consultants would provide the servicebased consultants would provide the service

Accommodation suggested that Leeds would pay hotel Accommodation suggested that Leeds would pay hotel costs for DGH consultants, agreed to an on call roomcosts for DGH consultants, agreed to an on call room

Issue of fitness to work the next day and compensatory Issue of fitness to work the next day and compensatory rest payment to the Trustrest payment to the Trust

Total cost for consultant on call reckoned by DGH Total cost for consultant on call reckoned by DGH participants at £1.2 million paparticipants at £1.2 million pa

Regional Cardiology rotaRegional Cardiology rota

After a series of meetings we invited the After a series of meetings we invited the Leeds Deputy Medical Director with Leeds Deputy Medical Director with responsibility for medical workforce issues responsibility for medical workforce issues to address the groupto address the group

He was verbally abused and no conclusion He was verbally abused and no conclusion reachedreached


We invited the Medical Director of the SHA We invited the Medical Director of the SHA to chair the next meetingto chair the next meeting

General level of tension lessenedGeneral level of tension lessened

After a couple more meetings agreement After a couple more meetings agreement was reached with the DGH employing was reached with the DGH employing Trusts with terms and conditions that were Trusts with terms and conditions that were mutually acceptablemutually acceptable


It is now all sweetness and lightIt is now all sweetness and light

Some solutions need high level external Some solutions need high level external pressurepressure

It’s not personalIt’s not personal

ConclusionsConclusions

Service centralisation can bring clear benefitsService centralisation can bring clear benefits

Staff have a high level of loyalty to their Staff have a high level of loyalty to their institutioninstitution

Cross site working is challenging because of the Cross site working is challenging because of the interdependencies of different servicesinterdependencies of different services

Senior Medical engagement is absolutely Senior Medical engagement is absolutely necessarynecessary

Some solutions need high level external Some solutions need high level external pressure from within or without the organisationpressure from within or without the organisation

ConclusionConclusion

It’s not personal (usually)It’s not personal (usually)

Thank youThank you

Documents

Learning from the Experience of Service Centralisation in Leeds