1. Whole systems planning Jane Austin Future Healthcare Network Jane.austin@nhsconfed.org January 2003

2. Summary About the Future Healthcare Network (FHN) Context Changing the shape of the system Changing the organisation of hospitals New planning system Conclusions

3. UK FHN Network Future Healthcare Network Modernisation Agency Information Authority Major Contractors Group DOH Policy Unit PFU NHS Estates Royal Colleges University Hospitals Network CABE Princes Foundation Information exchange Redesign Changing workforce Acute Reconfiguration PPP Acute Strategy Maternity/Paeds changes EPR Impact of IT on design Working with private sector Output specs Urban regeneration Streamlining procurement process Accommodation Training implications Design quality Building processes Sustainability Design quality NatPaCT

4. Overseas FHN Network Future Healthcare Network Modernisation Agency Information Authority Major Contractors Group DOH Policy Unit PFU NHS Estates Royal Colleges University Hospitals Network CABE Princes Foundation Information exchange Redesign Changing workforce Acute Reconfiguration PPP Acute Strategy Maternity/Paeds changes EPR Impact of IT on design Working with private sector Output specs Urban regeneration Streamlining procurement process Accommodation Training implications Design processes Design qaulity Sustainability Design quality Australia New Zealand European property network USA

5. Role of the Future Healthcare Network Innovation Implementation Policy development TrustsNHS Confed

6. Support for changes in the NHS Environmental design Workforce change Technology change Re-Design & clinical pathways Finance Innovation Implementation Policy development FHN System configuration Planning and PPP

7. Whole system thinking PCTs DOH policy unit Modernisation Agency NPDTNatPaCT NHS Estates Whole system planning PCT Network Hospital Network Best practice across all PCTs Best practice across all acute trusts Policy Development Acute trusts More care outside hospital. LIFT, Walk-in Centre,One stop shops, DTCs GP Premises and GP contract New models of care, Changing workforce, ICT, Building design Social care

8. Context No major building for 10+ years Knowledge base and skills out of date, fragmented Patient safety, staffing pressures New political imperatives New methods of building and procurement New culture

9. Centralisation of decisions: historically unbalanced CentralisationDecentralisation Workforc e Patient safety Patient experience Affordabilit y

10. … but now rebalancing... CentralisationDecentralisation Workforce Patient safety Patient experienc e Service delivery Affordability

11. … and influenced by new developments CentralisationDecentralisation Patient safety Patient experienc e Service delivery Training flexibility IT opportunities - remote diagnosis High tech equipment Affordability Workforce Clinical networks Role changes

12. So what is changing? Organisation inside hospitals Shape of health system

13. Changing the shape of the health system

14. Theatre Endoscopy Pathology Haematology Radiology Home Emergency Dpt Ward Outpatients Lung function Medical assessment unit GP Mortuary ? Chaotic health system

15. Components of the health system Specialist Tertiary hospital 500k pop District Hospitals (250k pop) Local care centre(s) 50- 100k pop GPs 2-10k pop Decentralisation of care

16. elective care Option 1 – Traditional model Complex cases Medically fit for discharge or for convalescence Medically fit for discharge District Hospitals (250k pop) emergency care Specialist Tertiary hospital 500k pop Local care centre(s) 50- 100k pop Main access Social care Selected access

17. Option 2 – Access at all levels Specialist tertiary hospital 24/7 Local elective care (ACAD) Local emergency care (BeCAD) Complex cases +ICT Medically fit for discharge Critical care Local elective: Local Emergency Main access Specialist access Local access ?16/7 Local Care Centre(s) Social care Local access

18. Option 3 - Local access + information highway Specialist tertiary hospital 24/7 ACAD: Local elective care BeCAD: Local emergency care Critical care Local ACAD: Local BeCAD Main access specialist ambulatory care Local access Strong ICT links Strong ICT links ?16/7 Main access Local Care Centre(s) Social care

19. Conclusions about redesigning the system Different models to fit local needs Decentralisation of care Seamless communication ICT is vital Redesign not relocate services in small hospitals Stakeholder (patient and staff) views important Move information not patients round the system Local access to care & diagnostics Local chronic disease management through clinical networks Changing the shape of the system

20. Changing the organisation inside hospitals

21. Changes in clinical practice + building design intermediate care (avoiding admission) NHS Direct Extended GP hours Minor injuries etc Specialist GPs Direct booking Outreach clinics Self care intermediate care (speeding discharge) at home packages nursing homes community hospital beds Step down / rehabilitation Theatres Diagnostics Critical care A&E & Acute Assess- ment Elective Ambulatory care Prevention Treatment Step down Assessment Follow ups Simple surgery Specialist GPs Primary care centres networks/links to specialist or teaching hospitals Specialist care

22. Patient pathway across an organisation A&EGPX-rayAmbulHomeLabsWard Sick patient better patient

23. A&E Diagnostic Investigation Critical Care Acute Inpatient Care Intermediate Care Facilities Ambulatory - 23 hr investigations & surgery Outpatients - Generalised - Specialised - One Stop Rehabilitation Low Dependency Respite Shared Care Home Care Social Care Community Primary Care Community + Primary Care Primary Care Community Patient Hotel Chest Pain Elderly Assessment Medical Surgical areas Peri Acute Care Graduated care process Care pathway

24. Oncology Haematology Palliative Care Pain Anaesthetics Liver Medicine Liver Surgery GI Medicine GI Surgery Renal Medicine Renal Surgery Urology Cardiology Respiratory Vascular Cardiac Surgery Ophthalmology Metabolic Rheumatology Stroke Acute Medicine & medical COE Neurology Neurosurgery Trauma Inpatient Aggregations Outpatient Aggregations Burns Plastic Surgery Breast Services Dermatology ENT Maxillo-facial Cardiac Med & Surgery VascularRespiratory Liver Medicine Liver Surgery GIRenalUrology ENTMaxfac NeurosurgeryNeurology Acute Med Acute Med & medical COERheumatology Dermatology Burns & Plastics Oncology & Radiotherapy HaematologyBreast Palliative Care Pain TraumaOrthopaedicsA&E OphthalmologyNeurosurgeryNeurology Metabolic Unit Objective: to create critical mass across which services can be effectively provided. Flexibility to meet demand. Optimisation through pull system Groupings (or aggregation) of patients according to care needs to achieve more homogeneity in terms of disease path, length of stay, skills and service requirements. New groupings away from traditional specialty based classifications. Body mapping for focused patient management..

25. NHS Direct Primary Care Urgents A&E Minors A&E Majors Crit CareAcute IP Recovery & Theatres Primary Care Chronics Outpatients Primary Care Follow-up Intermediate Care Rehab IP Step-down IP Elective IPDTC Urgent Treatment Step-downExpert consulting panel Acute care centre Elective Care Small scale organisation (NWLHT)

26. Conclusions: changing the shape inside hospitals Clinical aggregations combining medical + surgical specialties ICT is vital to be ready at the same time as building Diagnostic front door Hot floors Cellular construction round processes Increased local outpatients + reduced hospital waiting areas Patient focused care – Do we need Radiology departments? Staffability: consequences for the workforce

27. So, we need a new planning system…

28. Stage1 : Health systems with different starting points & drivers Workforce issues New standards & guidelines Building Maintenance Proposed planning process ( Pre SOC) Stage 3: Defining the limits of the possible Stage 5: Preferred option for whole system Stage 4: Options for change Stage 2: Developing the whole system vision Hospital-Community/Primary-Social Stage 7: Outline business case Workforce Change CommunicationsBuilding changes IT Patient and public involvement throughout the process, Stage 6: Strategies for organisations and functions Dialogue with Local People

29. Service planning and environmental design Service planning scale getting smaller>>>>>>>>> Environmental design getting more detailed>>>>>>>>>>> Estates strategy Outline designs Concept designs Detailed design Strategic overview Inside/outside hospital care New models of care Clinical aggregations Detailed design of components Care pathways Clinical components Life of project >>>>>>>>>>>

30. Integrated planning procurement Private public partnerships Changing workforce New Clinical models Building design Impact of technology Whole system configuration Inside hospitals Outside hospitals

31. New clinical models Changing workforce Impact of technology Building design Possible impact areas EUWTDE learning Redesign of clinical processes Standard components EPR Knowledge management Access to scarce skills Intelligent buildings Efficient building layout Changing roles Patient /staff environment Demography Environmentally robust

32. Timescale 29 large PFI projects phase 1 Projects 42 LIFT projects New procurement process pilots phase 2 pilots Next Election?

33. Conclusions

34. Key issues for the FHN 1.Ensure that the £value of good design is recognised 2.More resources to support service planning 3.Decentralisation of care and ICT – but how 4.Patient focused infra-structure what does it mean? 5.Adapt planning processes to new context? Who does what in the new system 6.Can we afford an increased workforce? 7.Future medical equipment needs

35. Issues for whole system planning PFI / LIFT interface What can be done outside hospitals Implications for GMS contract Chronic disease management Affordability Timescales