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The London Experience-Andy Mitchell

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Presentation given on
20 January 2012
Provision of Health Services in London
•Inefficiencies in provision of acute care with
poor use of estate
•Dependence on hospital care with failure to
transfer care to community
•Need for more specialised care on fewer sites
•Continuing health inequalities
•Dissatisfaction with services
Healthcare for London
�a comprehensive analysis of the need for change with principles
to guide improvement in care’ Kings Fund Report 2011
Stroke Care
Trauma Care
Hospital �Reconfiguration’
Improving access to Primary Care
Stroke reconfiguration
Investigation of the incremental cost, effectiveness and cost-effectiveness of the new
London Stroke Service in comparison with previous model. 6500 stroke episodes
Short run: 3yrs after stroke
Long run: 10 yrs after stroke
Outcomes measured in deaths averted QALYs
Analysis accounts for
Time from stroke onset to hospital admission
Time spent in hospital
Time after hospital discharge
At 30 days costs higher in new model by ВЈ3.3m. 214 fewer deaths. 51 additional
At three months costs lower by ВЈ5.4m. 238 fewer deaths. 112 more QALYs
At ten years for this cohort costs lower by ВЈ21m. 4492 QALYs gained
Cluster provide assurance to SHA on Implementation
The figure on the left compares the NHS
London’s HSMR with other SHAs. The London
figure is in red.
NHS London’s HSMR has consistently been
lower than all other SHAs. NHS London
HSMR has reduced from 94.9 in 2005 to 84.9
in 2011. This is a decreases of 11%, the
largest of any SHA. As the SHA is rebased
every year, the English HSMR remains at 100
across all years.
NHS London shown in red
Sustaining change
• Concerns re financial and clinical sustainability
– SAFE Project
• Continuing concerns over quality and safety
– Out of hours and weekend mortality
– NCEPOD reports
– Professional expressions of concern
Formal Review of Adult Medical and Surgical Emergency Services
Variation in on-site availability
Monday - Friday
Saturday - Sunday
Weekday London Average
Weekend London average
On-call consultant
•Weekdays range from
8 to 14 hours
•Weekend ranges from
0 to 12 hours
London hospitals
On-call consultant
• Weekdays range
from 5 to 12 hours
• Weekend ranges
from 2 to 12 hours
Across London sites half of consultants are not always freed from other
duties when on take
Not freed
Sometimes freed
• More than 50% of physicians
are not always freed from other
duties whilst on-take
Always freed
• Over 50% of surgeons are not
always freed from other duties
whilst on-take
Source: London trust survey March 2011
Variation also exists in access to key diagnostics which are crucial to
facilitate timely decision making and commencement of treatment
Number of key diagnostics available
London hospitals
Key diagnostics: X-ray, ultrasound, CT, MRI, interventional radiology and interventional endoscopy
Source: Survey of London acute trusts (2011)
Key messages from the case for change
There are over half a million emergency admissions to London’s hospitals each
year, amongst the sickest of our patients.
A patient admitted to hospital in an emergency has little choice in where or
when they attend. The public trust and expect consistently safe and high quality
services 24 hours a day, seven days a week; London is not meeting this
– Workforce pressures such as EWTD, a future reduction in junior doctors and
consultant sub-specialisation mean that the way services are currently delivered
is not sustainable
The self-reported survey of London Trusts shows significant variation in service
provision, especially out-of-hours.
Poor out-of-hours emergency service provision is associated with an increased
variation in outcomes such as lengths of stay, re-admission rates and mortality
London needs to provide a seven day consultant delivered service to
address the case for change
Commissioning standards have been developed to address the issues
raised in the case for change: to ensure that consultants have early and
continued involvement in the care of all patients admitted as an
The development of the standards was clinically led and informed by the
patient panel and wider stakeholder groups through continued engagement
during the review
Emerging standards were also shared with the Royal Colleges for feedback
and comments throughout development
The standards represent the minimum quality of care that patients admitted
as an emergency should expect to receive in every hospital in London that
accepts patients on an emergency basis
All standards cover the seven days of the week – there should be no
difference in the provision of emergency services during the week
compared to those at the weekend
Commissioning: Core standards
All emergency admissions to be seen and reviewed within 12 hours
A clear multi-disciplinary assessment to be undertaken within 12 hours and
a treatment plan to be in place within 24 hours
All patients admitted acutely to be continually assessed using a
standardised early warning system
When on-take, a consultant and their team are to be completely freed from
any other clinical duties/ elective commitments
Consultant work patterns are to meet the demands for consultant delivered
care with extended day working across the AMU/ ASU, seven days a week
All patients on the AMU/ ASU to been seen and reviewed by a consultant
during twice daily ward rounds
All hospitals admitting emergency patients to have 24/7 access to key
diagnostic services
All hospitals admitting emergency patients to have 24/7 access to
interventional radiology
Commissioning processes
Commissioning intentions 2012/13
– Standards will be included in pan-London commissioning intentions
– Evidence to be sought from providers that standards are in place and
for ongoing monitoring
Commissioning strategy planning 2012/13 – 2014/15
– The commissioning standards should be integral to commissioner’s
– Plans are expected to outline the likely service impact for providers
following discussion
System wide approach
– In the event some providers are not able to meet the standards a
process to evaluate the range of options available to commissioners to
deliver the standards is proposed
Additional Critical Services
• Paediatric Medical and Surgical Services
Critical Care and Anaesthesia
Emergency Medicine
Maternity Services
Interventional Radiology
Emergency Orthopaedics (Fractured NoF)
The Future
London Clinical Commissioning Council
London Clinical Senate
Senate Council
Professional Advisory Groups
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