Hospital services hanging in the balance could affect Bolton patients

The document, which is to be presented to a powerful committee of GPs next week, states that neither retaining the A&E in its current part-time form nor restoring a round-the-clock service would make clinical sense – because of the staffing issues which required the department to reduce its hours in the first place.

But the prospect of the two districts not only retaining the facility, but also seeing it enhanced, has not been completely ruled out – after a public engagement process heard “concern” over the possibility of the site being downgraded.

However, the chance that the A&E in its present form will shut its doors – with the facility turned into a 24-hour urgent treatment centre – also remains.

The report’s authors describe some of the options presented as possibly being “difficult for some people to accept”.

Under all of the proposals, the hospital itself would remain open and would be able to stabilise any patient brought through its doors, before – if necessary – transferring them elsewhere if services at Chorley are changed. 

Chorley A&E has been operating on a part-time basis for over two years and spent much of 2016 completely closed, because of a shortage of middle-grade doctors to cover shifts at the unit and the A&E at the Royal Preston – both of which are operated by Lancashire Teaching Hospitals (LTH).

Since then, NHS leaders have been exploring the future shape of urgent and emergency care services across Central Lancashire and a group of medics, ranging from consultants to GPs, have spent the last year drawing up a series of options.

The outcome of that process has been the publication of five broad options to reconfigure the system. 

A joint committee of the Greater Preston and Chorley and South Ribble clinical commissioning groups (CCGs) will decide how many out of a total 13 – often slightly nuanced – proposals is taken forward.   It has been recommended that five of them be taken off the table now, because they are deemed either clinically or financially unviable.

But the possibility of returning the current A&E service at Chorley to a 24-hour operation – and even upgrading it to the kind of emergency facility which has not operated on the site for over a decade – has been left in play, in spite of the local clinicians who developed the options concluding that it would not be viable.

The Royal College of Emergency Medicine (RCEM) also warned that such a move would risk making existing staffing challenges across the trust worse – and would “prove rapidly unsustainable and fail”.

“We have heard quite clearly from public engagement events that there is a lot of concern around the A&E model, – so we want to make sure we’re exploring it fully, Jason Pawluk, Delivery Director for the Our Health Our Care (OHOC) programme, said.  

“The problem we have is how far it is going to be possible to attract the necessary workforce and – because of a lack of capital – how we will be able to invest in the infrastucrure to make it happen.   But if there is an option for acquiring future capital, we’d like to look at how that could be applied to any of the proposed models so we are keeping an open mind.

“RCEM’s evidence is helpful, but it is just one perspective – and I wouldn’t expect all of the evidence we have received to say the same thing.”

A group of local care professionals has also been reviewing the plans.

The option of continuing with the A&E facility in its current form – even set against a backdrop of work across the health and social care sectors to reduce pressure on urgent care services – has been recommended for refusal.     

RCEM concluded that there are “significant concerns about the safety of the current model” – because of limited senior emergency department staff during evenings and weekends and the “paucity” of supporting services at Chorley Hospital.

A so-called “do nothing” approach is also set to be taken forward – but primarily as a way to determine how the proposals would compare to the existing arrangements.

The two other overarching options involve the existing A&E closing and being replaced with two variations on an urgent treatment centre (UTC).

The first of the two would be an “enhanced” UTC, which would go beyond the national minimum national guidelines for such a facility by being staffed by “senior acute medicine decision makers” for 12 hours per day and GP-led the rest of the time.    Patients with urinary tract infections, anaemia and low-risk respiratory conditions could be treated in such a unit.

An enhanced UTC would also operate a so-called “ambulatory care” facility, designed to ensure patients can return home the same day, without being referred elsewhere to be admitted.   

“It allows consultant assessment and secondary care treatment without them being brought in to stay.   The patient gets home sooner and we avoid putting patients unnecessarily into ward beds, which improves the overall capacity of the hospital,” Jason Pawluk said.

This option could come to be described as a “local A&E”, in line with the emerging concept for such a service outlined in the NHS ten-year plan published back in January.

The second of the two remaining broad options would see a basic UTC service operating at Chorley 24 hours a day – a downgrading of what is currently available during daytime hours.    Conditions which could be treated under that model include minor injuries, infections and ailments – and it is claimed that more than eight out of ten people in need of urgent services could be treated in a UTC. 

Jason Pawluk said the successful implementation of either of the UTC models – which also include variations on other aspects of the hospital services provided – would depend on ensuring public awareness of what type of treatment was on offer at each of the Chorley and Preston sites. 

“If a patient walked in to Chorley [under a UTC scenario], there would be an ability to stabilise and manage even a critically unwell person – and then transfer them to Preston.   

“But when these changes are done in a planned way and way, the level of understanding about where to go tends to be better than when things happen in an unplanned way as they did back in 2016.”

The North West Ambulance Service and NHS 111 phoneline would receive guidance about the most suitable hospital destination for a patient in their care.

The proposals have not factored in any considerations about the capacity of the Royal Preston’s A&E to cope with any increase in patients.   The modelling has assumed that work in the wider health and social care system to reduce demand on emergency facilities will see usage fall by five percent – “more than [enough] to offset any increases” as a result of the options being proposed, the report notes.

Mr Pawaluk says he is comfortable with the assumption being made.

“Good examples of work already done to improve performance locally and elsewhere in the country have shown improved connections between different parts of the wider system help to avoid unnecessary admission to hospital.

“Hospital change is one part of the bigger picture,” he added.

WHAT HAPPENS NEXT?

The joint OHOC committee of Central Lancashire’s two CCGs will decide on 28th August whether to accept the recommendation to further investigate the eight options which it is thought should be left on the table.

These will then be considered by an NHS clinical senate – a group of senior NHS medics from other parts of the country who will independently assess their viability.    Their report will be considered by the OHOC joint committee before it is decided whether to approach NHS England to launch a formal public consultation.

The public need to be asked for their opinion if any of the proposals represent a “major” change to services – the proposals for urgent treatment centres would come under that bracket.   There is no set figure for the final shortlist of options – but it will be fewer than the eight recommended to be investigated further at the current stage. 

The two CCGs would then make a final decision, informed – but not bound – by the consultation outcome.    OHOC programme director Jason Pawluk says that the public’s ability to comment will not be dictated by the shortlist. 

“If they feel there is an option which is not on the table and should be, they can say so,” he said.

The earliest point at which a consultation could happen is expected to be Spring 2020 – and the timing could be affected by local elections.

SUPER HOSPITAL SCRAPPED?

Long-mooted plans for a so-called super hospital on a single site in Central Lancashire are absent from a list of options for the future of the region’s A&Es – because funding for the idea has never been found.

Papers to be presented to a meeting of the region’s Clinical Commissioning Groups next week reveal that an unpublished feasibility study into the concept in 2016 costed such a project at £569m.

But the possibility of a new build hospital cannot be formally considered by local NHS leaders if there is “a clear lack of evidence that it is deliverable”, an OHOC report notes.

“We are obviously prepared to revisit the idea if capital becomes available – but it would still be a very long-term solution and we’re looking at doing the right thing for patients now.   We have to do our best with what we’ve got,” OHOC programme director Jason Pawluk said. 

The current proposals could also benefit from – but are not reliant upon – capital funding and it is expected that cash will be sought from any national funding pots which become available.

Central Lancashire was unsuccessful in a bid for more than £50m of capital investment last year.   The region also failed to appear on a list of hospital investments and upgrades announced by the government earlier this month.

WHAT ELSE COULD CHANGE?

The range of options for redesigning non-emergency services at Chorley Hospital includes some which would involve the site undertaking more pre-planned surgery.

 If it was ultimately decided to create an enhanced or basic urgent treatment centre, there would be various ways in which the hospital’s other beds and wards could be reconfigured.

“Some of the options would allow more elective surgery to be delivered on the Chorley site, while more medicine [unplanned] patients would be treated at Preston,” Jason Pawluk, OHOC’s programme director explained.   .

“So if you’re a medicine patient from Chorley or South Ribble, you might have to travel further to Preston.   But if you are a day case patient living in Chorley or South Ribble, you could end up having your planned surgery closer to home.”

It is estimated by Central Lancashire’s CCGs that reduced transport costs could save Chorley and South Ribble patients £400,000 each year.

An earlier draft of the model of care – on which the options for the future of Chorley Hospital are based – suggested that Central Lancashire could benefit from a “ringfenced” facility for pre-planned care to prevent operations being cancelled as a result of pressures elsewhere in the hospital system. 

“We are not using the term ringfenced now – but if capacity can be created at the Royal Preston by improving [a patient’s length of stay], then there is an opportunity to create a centre at Chorley for planned day cases and shorter [hospital] stays.   However, it would be contingent on being able to make other changes [to urgent care] as you would need the space to implement it,” Mr. Pawluk added.

Some of the other options include retaining more general, medicine and specialty beds at Chorley – as well as a level 3 critical centre for the sickest patients. 

WHAT IS ON THE TABLE?

This is the long-list of options for the future of Chorley A&E and some of the hospital’s other services, which will be discussed by senior GPs next week.

Option 1 – No change

Continue with the current 12-hour A&E facility and co-located urgent care centre – and make no changes to other services.

Assessment:  not clinically viable – due to staffing issues and absence of other key clinical services in Chorley Hospital.

Recommendation:  add to shortlist (as a benchmark for other options)

Option 2 – No change, but implement wider system transformation

As above but against the backdrop of continuing to implement policies to reduce A&E pressure – including plans to keep people out of hospital or reduce their length of stay. 

Assessment:  not clinically viable – for same reasons as option 1

Recommendation:  do not add to shortlist 

Option 3 – Reinstate 24-hour A&E opening/upgrade A&E

Either reopen the department 24 hours a day at its existing level (a so-called “type 3” facility, without co-located services such as emergency surgery and inpatient paediatrics) or upgrade to a “type 1” facility like the Royal Preston and reintroduce some services at Chorley which have been absent for 10-20 years.

Assessment:  not clinically viable – due to staffing

Recommendation:  add to shortlist (to “keep an open mind” on the basis of opinions expressed during public engagement)

Option 4a – Enhanced urgent treatment centre (UTC) with level 3 critical care unit

UTC staffed by “acute medical senior decision-maker” for 12 hours a day and GP-led during evenings/overnight.  Plus, observation, medical assessment beds and general/speciality beds provided.

Assessment:  clinically viable – investment in workforce required

Recommendation:  add to shortlist

Option 4b – as 4a, but without general/specialty beds

Assessment:  not clinically viable – due to delay caused to reviews by specialist consultants

Recommendation:  do not add to shortlist

Option 4c – as 4a, but without medical assessment or general/specialty beds

Assessment:  clinically viable 

Recommendation:  add to shortlist

Option 4d – Enhanced UTC, without level 3 critical care unit

No medical assessment or general/specialty beds, but an enhanced care unit to deliver level one post-operative care – meaning more planned surgery performed at Chorley.

Assessment:  clinically viable 

Recommendation:  add to shortlist

Option 4e – as 4d,  but without enhanced care unit

Assessment:  not clinically viable – due to adverse impact on existing surgical capacity at Chorley.

Recommendation:  do not add to shortlist

Option 5 – Urgent Treatment Centre 

24-hour UTC as currently operates on the Chorley site, without the presence of an acute physician.

There are 5 variants of this proposal, a)-e) – apart from offering a UTC rather than an enhanced UTC, they correspond with options 4a)-4e) above and so the assessments and recommendations for each are the same.    Therefore, options 5a), c) and d) are deemed clinically viable, while options 5b) and e) are not.