whole systems planning

Whole systems planningJane Austin

Future Healthcare [email protected]

January 2003

Summary

• About the Future Healthcare Network (FHN)

• Context• Changing the shape of the system• Changing the organisation of

hospitals• New planning system• Conclusions

UK FHN Network

Future Healthcare

Network

Modernisation Agency

Information AuthorityMajor Contractors Group

DOH Policy Unit

PFU

NHS Estates

Royal Colleges

University Hospitals Network

CABEPrince’s Foundation

Information exchangeRedesignChanging workforce

AcuteReconfiguration

PPPAcute Strategy

Maternity/Paeds changes

EPRImpact of IT on design

Working with private sectorOutput specs

Urban regeneration

Streamlining procurement process

AccommodationTraining implications

Design qualityBuilding processes

SustainabilityDesign quality

NatPaCT

Overseas FHN Network

Future Healthcare

Network


Information Authority Major

Contractors Group

DOH Policy Unit

PFU

NHS Estates

Royal Colleges

University Hospitals Network

CABEPrince’s Foundation

Information exchangeRedesignChanging workforce

AcuteReconfiguration

PPPAcute Strategy

Maternity/Paeds changes

EPRImpact of IT on design Working with private sector

Output specsUrban regeneration

Streamlining procurement process

AccommodationTraining implications

Design processesDesign qaulity

SustainabilityDesign quality

AustraliaNew Zealand

European property network

USA

Role of the Future Healthcare Network

Innovation

ImplementationPolicy

development

Trusts NHS Confed

Support for changes in the NHS

Environmental design

Workforce change

Technology change

Re-Design & clinical pathways

Finance

Innovation

ImplementationPolicy

development

FHN

System configuration

Plann

ing

and

PPP

Planning and P

PP

Whole system thinking

PCTsDOH policy unit


NPDT NatPaCT

NHS Estates

Whole system planning

PCT Network

Hospital Network

Best practice across all PCTs

Best practice across all acute trusts

Policy Developmen

t

Acute trusts

More care outside hospital.LIFT, Walk-in Centre,One stop shops, DTCs

GP Premises and GP contractNew models of care,

Changing workforce, ICT, Building design

Social care

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

Centralisation of decisions: historically unbalanced

Centralisation Decentralisation

Workforce

Patient safety Patient

experience

Affordability

… but now rebalancing ...


Workforce Patient safety

Patient experienc

e

Service delivery

Affordability

… and influenced by new developments


Patient safety

Patient experie

nce

Service delivery

Training flexibility

IT opportunities - remote diagnosis

High tech equipment

Affordability

Workforce

Clinical networks

Role changes

So what is changing?

Organisation inside hospitals

Shape of health system

Changing the shape of the health system

Theatre

Endoscopy

Pathology

Haematology

Radiology

Home

Emergency DptWard

Outpatients

Lung function

Medical assessment

unit

GP

Mortuary

?

Chaotic health system

Components of the health system

Specialist Tertiary hospital500k pop

District Hospitals (250k pop)

Local care centre(s)50- 100k pop

GPs2-10k pop

Decentralisation of care

elective care

Option 1 – Traditional model

Complex cases

Medically fit for discharge

or for convalescence

Medically

fit for

discharg

e

District Hospitals (250k pop)

emergency care

Specialist Tertiary hospital500k pop

Local care centre(s)50- 100k pop

Main access

Social care

Selected access

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

Critic

al

care

Local elective:

Local Emergency

Main access

Specialist access

Local access

?16/7

Local Care Centre(s)

Social care

Local access

Option 3 - Local access + information highway

Specialist tertiary hospital

24/7

ACAD: Local elective care

BeCAD: Local emergency care

Critic

al

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

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

Chan

gin

g t

he s

hap

e o

f th

e

syst

em

Changing the organisation inside hospitals

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

DiagnosticsCritical

care

A&E & Acute

Assess-ment

Elective

Ambulatory care

Prevention

Treatment

Ste

p d

ow

n

Assessment

Follow ups

Simple surgery

• Specialist GPs• Primary care centres

• networks/links to specialist or teaching hospitals

Specialist care

Patient pathway across an organisation

A&EGP X-rayAmbul’Home Labs WardSick patient

betterpatient

A&EDiagnostic

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

Com

mu

nit

y +

P

rim

ary

C

are

Primary Care

Community

Patient Hotel

Chest Pain Elderly

Assessment

Medical Surgical areas

Peri Acute Care

Graduated care processGraduated care process

Care pathway

OncologyHaematology

Palliative Care

PainAnaesthetics

Liver Medicine

Liver Surgery

GI MedicineGI Surgery

Renal Medicine

Renal SurgeryUrology

CardiologyRespiratory

VascularCardiac Surgery

Ophthalmology

MetabolicRheumatolog

y

Stroke

Acute Medicine& medical

COE

Neurology

Neurosurgery

Trauma

Inpatient Aggregations

Outpatient Aggregations

Burns

Plastic SurgeryBreast

ServicesDermatology

ENTMaxillo-facial

Cardiac Med Cardiac Med & Surgery& SurgeryVascularVascular

RespiratoryRespiratory

Liver Liver Medicine Medicine

Liver SurgeryLiver SurgeryGIGI

RenalRenalUrologyUrology

ENT ENT MaxfacMaxfac

NeurosurgerNeurosurgeryy

NeurologyNeurology

Acute Med Acute Med & medical COERheumatologRheumatolog

yyDermatologyDermatology

Burns & Burns & PlasticsPlastics

OncologyOncology& &

RadiotherapyRadiotherapyHaematologyHaematology

BreastBreastPalliative Palliative

CareCarePainPain

TraumaTraumaOrthopaedicsOrthopaedics

A&EA&E

OphthalmoloOphthalmologygy

NeurosurgerNeurosurgeryy

NeurologyNeurology

Metabolic Metabolic UnitUnit

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.

.

NHS Direct

Primary Care Urgents

A&E Minors

A&E Majors

Crit Care Acute IP

Recovery & Theatres

Primary Care Chronics

Outpatients

Primary Care Follow-up

Intermediate Care

Rehab IP

Step-down IP

Elective IP DTC

Urgent Treatment Step-down Expert consulting panel

Acute care centre

Elective Care

Small scale organisation (NWLHT)

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

So, we need a new planning system…

Stage1 : Health systems with different starting points & drivers Workforce

issuesNew 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 ChangeCommunications Building

changesIT

Pati

en

t an

d p

ub

lic in

volv

em

en

t th

rou

gh

ou

t th

e

pro

cess

, Stage 6: Strategies for organisations and functions

Dialogue with Local People

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 >>>>>>>>>>>

Integrated planning

pro

cure

men

t

Private public partnerships

Changing workforce

New Clinical models

Building design

Impact of technologyW

hole

syst

em

con

fig

ura

tion

Inside hospitals

Outside hospitals

New clinical models

Changing workforce

Impact of technology

Building design

Possible impact areas

EUWTD E learning

Redes

ign

of

clin

ical

proc

esse

s

Stan

dard

com

pone

nts

EPR

Knowledge management Access to

scarce skills

Intelligent buildings

Efficient building layout

Changing roles Patient

/staff environment

Demography

Environmentally robust

Timescale

year 1 year 2 year 3 year 4 year 5 year 6 year 7 year 82002/3 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10

PFI Building process

DTC development

Primary building process

Technology procurement

Care redesign processes

Workforce change

29 large PFI projects phase 1

Projects

42 LIFT projects

New procurement process

pilots

phase 2

pilots

Next Election?

Conclusions

Key issues for the FHN

1. Ensure that the £value of good design is recognised

2. More resources to support service planning3. Decentralisation of care and ICT – but how4. 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

Issues for whole system planning

• PFI / LIFT interface• What can be done outside

hospitals• Implications for GMS contract• Chronic disease management• Affordability• Timescales

whole systems planning

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