“We build on a noble heritage".

A century of health services development in Birmingham in the context of the broader political and

social environment

Where did it all begin? • Metchley Roman Fort is on

the same site as the QE.

• Originally a Roman staging

post on Icknield Street to

protect communication

routes.

• Archaeological evidence

shows sporadic use but there

is some evidence of a

medical function.

Hospitals in Birmingham

• Hospitals mainly providers to the poor pre 1914.

• Voluntary Hospitals & Municipal Hospitals.

• In Birmingham a number of charitable hospitals:

General 1770 [rebuilt 1897], Queens 1841,

Orthopaedic 1817, eye 1823, The Earl 1843,

Dental 1858, Children’s 1862, Women’s 1871 &

Skin 1881.

• Main Municipal Hospitals at Selly Oak and

Dudley Road.

Social Change • Doubling of population

between 1881 and 1921.

• Industrialisation and the motor

car led to an increase in

accidents (50,000 accidents

by 1920).

• Resources diverted to

munitions during the war

leading to overcrowding.

• Societal change brought about

by the war led to greater use

of hospitals by the middle

classes.

Date Population

1087 100

1546 2,300

1700 15,000

1801 73,670

1881 401,000

1921 922,000

1931 1,002,000

1951 1,100,000

2011 1,074,000

Medical Advances • Aseptic techniques and

antiseptics led to Golden age of

surgery between 1900-20.

• Roentengen’s work on x-rays

published in 1896.

• Development of specialist

diagnostics & discovery during

wartime.

• Antibiotics & Insulin.

• “The second quarter of the 20th

Century was the Golden Age of

Medicine “ Stanley Barnes

Municipal Hospitals • Workhouses were

transforming into Hospitals.

• At Selly Oak, a separate

infirmary was built in 1897 at

a cost of £52,000.

• Dudley Road was upgraded

for military use during the

war.

• Being Municipally funded the

hospitals were better placed

to access new technologies.

Birmingham General Hospital

• First purpose built hospital in

Birmingham (1779 Summer

Lane).

• Rebuilt on Steelhouse Lane in

1897.

• Site landlocked and

architecturally constrained.

• Demand outstripping supply by

early 1920 and no expansion

space to meet medical advances

eg physiotherapy situated in the

carpenters workshop.

Birmingham Queen’s Hospital • Opened in 1841 & named

after Queen Victoria.

• Built mainly for clinical

instruction.

• Opened with approximately

100 beds.

• Extended in 1868

(outpatients) and a nurses

home added in 1887.

• Further expansion in 1908

and in 1925.

Birmingham Medical School • Initially established in 1828 to remove young men from

the “distractions and allurements of the Metropolis”.

• The School of Medicine was situated near the Town Hall

in Queen’s College and could accommodate the

teaching but not the clinical experience.

• To meet the clinical aspects of medical education Sands

Cox a lecturer in anatomy established the first hospital to

support medical training at the Queen’s Hospital.

• The General Hospital established a rival school to attract

apprentices known as the Sydenham School.

• The 2 schools were merged in 1868 and became the

Faculty of Medicine on the establishment of the

University in 1900.

Post War Birmingham Health Economy

• Voluntary Hospitals charitable donations

dwindled during the war and post war years.

• Cost of care also rising due to medical

advances and growing demand.

• Nationally Voluntary Hospitals running into

debt but were too big to be allowed to fail.

• Government made half a million pounds

available to support voluntary hospitals.

• To access the funds Voluntary Hospitals had to

join and abide by the decisions of the Local

Voluntary Hospitals Committees.

General Hospital Response made by the Medical Committee

Medical Committee reported to the Management Board in

December 1922:

• An additional 130 beds

• Purpose built x-ray facility-double the size and triple the

equipment

• 4 new operating theatres

• 50% increase in Casualty and Observation ward

• 50% increase in outpatients.

• Increase in Physiotherapy space.

• New departments of bio-chemistry and clinical

pathology

The Board’s response?

• Established “THE EXTENSION

COMMITTEE”.

• First meeting Jan 1923.

• Reported in October 1925.

• All requests for additional beds to be

presented to the Local Voluntary

Hospitals Committee.

• LVHC recommended:

“That no decision be taken on the proposal to extend the bed accommodation in the centre of

the city until full enquiry has been made through the Ministry of Health and other

available sources as to the comparative cost and efficiency of general hospital extension in open

suburban areas compared with extension on the central site”.

“The work of an irresponsible body of men who had no

interest in the General Hospital”.

Board Member

Consequences of LVHC Decision • All further expansion of the

Queen’s and General Hospital

delayed / stopped.

• No public appeal for funds without

LVHC sanction.

• Main opposition to the General

Extension came from Alderman

WA Cadbury.

• Cadbury vision to create a 100

acre suburban site to provide for

Birmingham’s population for the

next 50 years.

Grant Robertson Committee Established • Invited the General & Queen’s

Hospital to consider a scheme

to consider a new Hospital

Centre adjacent to the new

University.

• The invitation was accepted by

both organisations

[unthinkable 5 years before

due to the animosity between

the 2 organisations].

• Steering Committee to be

chaired by Mr Charles Grant

Robinson Principal of the

University.

Birmingham Hospitals

Centre

Birmingham General Hospital

University of Birmingham

Queen’s Hospital

Grant Robertson Report Reported within 6 months in 1926 and unanimously

approved at the Hospitals Council in October 1926:

1. New Centre established adjacent to UoB site.

2. General & Queen’s amalgamated as quickly as

possible [achieved in 1933].

3. The amalgamated institution would have access to

1,200 beds.

4. New Hospital should have a minimum of 750 beds.

Work began on planning the new Medical Centre

sponsored by Alderman Cadbury who bought and

donated the site in 1926 and funded visits to medical

centres across Europe and an early rejection of the

traditional pavilion system.

1926 -31 • Executive Board established in 1927 but progress was

slow with no infrastructure to support the scheme and its

members fulfilling full time roles at their home

institutions.

• Had to resolve a legal issue with the Board of Trade as

to how the 2 legal entities could transfer a £1m asset to

a legal entity which did not exist.

• After an initial influx of funds bringing in nearly £500,000

the number and value of charitable donations dwindled.

• A decision was made to scale back the bed numbers

from 750 to 500 but maintain the ancillary services and

design in expansion space.

Controversy & Challenge –”A Birmingham Medical Man” Nov 1931

• Concern that the new

centre would mean the loss

of medical students &

status.

• Financial pressure due to

rising costs and poor

economic outlook

(Municipal Albatross).

• Birmingham had increased

by 879 beds since 1925.

Birmingham Hospitals Centre

Finance

Capacity

Identity

Battle lines are drawn – The Midland Institute Meeting – Jan 4th 1932

• Controversy came to a head at a public meeting

held in the Midland Institute.

• Opponents to the scheme included several

senior clinicians, the Municipal Medical Officer

and the Chancellor of the Exchequer.

• Supporters included the Subscribers to the fund,

The Hospitals Committee, The Hospitals

Saturday Fund and the Dunlop Rubber

Company.

• The supporters won the day by a relatively small

majority of 42.

Finally work begins

• Construction began in

1933 by The United

Birmingham Hospitals.

• Foundation stone laid by

the Prince of Wales 1934.

• Donations increased to

£1,158m to cover the initial

building cost.

• Construction and

commissioning completed

on the 1st of March 1938

and named after the

Queen.

Underlying planning principles in the late 1920’s:

• To maximise efficiency the Hospital Centre

to accommodate medical students and

faculty with appropriate specialisms in one

place.

• Optimum bed occupancy to be 85%.

• Optimal flexibility in bed use through a

combination of ward / room sizes ranging

from single rooms to 16 bed.

• Novel design and innovation in

heating/ventilation.

• Advanced activity modelling.

1940’s & 50’s • The QE immediately put

under pressure during the

war and increased from

540 to 750 beds.

• 1948 NHS established

and UBH transferred to

NHS.

• 1950 School of Nursing

opened.

• Nurse staffing 75 female

and 1 male [nursing

supported mainly by

students approx 500].

1960 to 1990 • 1968 Womens Hospital opened.

• First Computer used at QE in the

late 1960’s.

• Cardiac Pacemakers part of great

medical advances such as CT

Scanning, ultrasound and nuclear

imaging.

• MRI and renal dialysis

• First Liver Transplant in 1982 [now

the largest programme in the world.

• Ill fated Ackers Plan.

The brink of a 3rd IR driven by electronic communication

• Steam, Petrol &

Electronic.

• Medical technology

incrementally advancing.

• Digital technology is

providing the disruptive

change for transformative

change.

• Potentially offers a route

to balance supply &

demand.

Jeremy Rifkin 2011

The third wave of Medicine

“Eminence Based Medicine”

“Evidence Based Medicine”

“Precision Medicine”

Social Change • Youngest [and highest

obesity] population in Europe.

• Social Media creating societal

change

• New technology supporting

precision medicine

• 35% increase in A&E

attendances [only 56% of

people knew who to contact at

night].

• Life expectancy [living longer

but not better]

Origins of the new QE

• Financial crisis in South

Birmingham HA led to

drastic reductions in service.

• Selly Oak & QE merged,

Accident Hospital closed in

1995.

• Smethwick Neurosurgical

Hospital closed 1996.

• Birmingham General closed

in 1997.

Urgent need for renewal

• £100m+ repair costs

• Two sites

• New technology

• Infection prevention

• New clinical needs

Key drivers

• Improve patient care

• Meet rising patient expectations

• Improve efficiency

• Complexity of Medicine

• Education and training

Planning started in 1999

• 21 Short Life Working Groups.

• Over 2000 Clinical Staff

involved in planning process.

• Detailed activity modelling.

• Invitation to Tender 2002.

• Preferred Bidder selected in

2003.

Preferred Bidder Process

Jan Oct Jan Dec Jun Nov June

2004 2004 2005 2005 2010 2010 2011

Preferred Bidder Selected

1:200 Scale Clinical Planning

1:200 Scale Sign-Off

1:50 Scale Clinical Planning

1:50 Scale Sign-Off

Phase I

Phase 3

Phase 2

A&E CDU

Outpatients

Laboratory services, Mortuary, Service yard

Ambulatory care/Day case Imaging

Therapies Uni research labs, Education & training

Theatres Critical care/Burns

In patient Wards

In patient Wards

In patient Wards

In patient Wards

In patient Wards

Designing world class services

Beds in New Hospital - 1233

Bed Type: Current New Hospital Difference: Current

& Future

> 23 hrs (inc PPU) 1035 899

(inc. 36 growth)

-136

Assessment Trolleys +

Recliners

10 32 + 22

Critical Care 86 100

(inc. 14 growth)

+ 14

< 23 hrs

Beds and trolleys

64 64 0

< 23 hrs

Recliners

12 61 + 49

Dialysis Recliners 37

41 + 4

Decant Ward 0 36 + 36

TOTALS 1244 1233 - 11

Clinical Strategies to deliver new models

of care

• Reduction in avLOS (eg Increase preadmission: tight

control of LOS: new ways of working (RATS)

• “On Demand” Diagnostics (Front door = 4hrs: inpatients

24hrs MAX for diagnostics& intervention

• Reduction in beds days lost: (delayed discharge: HAIs)

• Activity conversion to ambulatory / short stay

• 7 day working

• ICT development to support new ways of working - eg

ELOS: “real-time” digital data retrieval & entry

Major Challenges

• Achieving “fit”.

• Paperless Hospital

• Clinical Aggregations.

• Managing the front door.

• Maintaining Quality

Another Intervention by No11

• Chancellor of Exchequer

again argues QE should

be delayed.

• Gordon Brown against

PFI.

• Borrowing to Capital ratio

changed by PFU.

• BoD approves the

World’s most expensive

hole in the Ground.

• PFU undertakes review.

Approval is achieved • Road to Affordability project

achieves new PFI ratio.

• 3 wards shelled & other

compromises made (oncology)

• WM SHA and SB’ham PCT approve

scheme.

• PFU agree revised finance model.

• Opposition to single site scheme

wanes following PFU approval.

• Sandwell & West Birmingham

announce 2010 project.

• 44% single rooms

• Integrated services

• Co-location of specialties

• Latest technology

• Leading edge care

• Great visitor facilities

Critical Care Unit

Theatres

Electronic Data Capture in OPD

• Consultation workflow

• Co-Morbidities (Quick Pick)

• Drug History & Prescribing

• Clinical Noting

• Clinical Observations

• Concept of face-to-face or

non face-to-face

consultation

• Integrated digital pen

• Integrated with WinScribe

Facilitates a Journey from this -

To this…..

And this…

Comparison of the 2 QE’s Old QE

• Controversial

• 12 years from inception to

occupation.

• 540 beds

• 7 Theatres

• State of the art labs &

imaging.

• Structural change –LVHC

• Plans for Children’s

Hospital

• Leveraging benefit from

campus

New QE

• Controversial

• 12 years from inception to

full occupation.

• 1,213 beds [c 1,400 beds]

• 32 Theatres

• 3T MRI, 5 MRI, 6 CT and

automated labs.

• STP & Devo

• Plans for Children's

Hospital

• Leveraging benefit from

campus

The Future

• Devolution agenda

• Ageing and morbidity

• Big Data pro’s and con’s

• Birmingham Metropolitan Hospital

• Precision or Personal Medicine

• Will the wealthy return to care in

their own homes?

Questions?