Kent and Medway Stroke Review - Dartford and Gravesham NHS Trust Deliverability Panel
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Appendix Wiv
Kent and Medway Stroke Review
Dartford and Gravesham NHS Trust
Deliverability Panel
1
Contents
• Background and context
• Overview of the options
• How we will deliver the capacity
• How we will implement the model
Please note - the following are indicated throughout the presentation against the
relevant icons:
! Identified risks (also provided in Appendix A)
Examples of our track record
Quotes from relevant stakeholders
2
Background and context
Stoke services across the region have been challenged,
particularly as the review has been ongoing
• The performance of Dartford and Gravesham performance
stroke services
across the Kent and
2017/18
2013/14
2014/15
2015/16
2016/17
Medway region have
been inconsistent,
leading to this
review
• Scanning key indicators
As most Trusts in the
region, Dartford and Percentage of patients scanned within 1 hour DGT 42.7% 51.4% 50.3% 53.0% 49.7%
Gravesham has of clock start
faced challenges, National 41.9% 44.1% 47.5% 51.3% 52.6%
particularly during Stroke Unit key indicators
the review
Percentage of patients directly admitted to a DGT 33.1% 59.2% 41.2% 30.1% 27.1%
stroke unit within 4 hours of clock start National 58.0% 56.8% 58.3% 57.4% 57.2%
Percentage of patients who spent at least 90% DGT 79.7% 88.7% 84.0% 67.2% 66.3%
of their stay on stroke unit National 83.0% 81.9% 83.5% 83.8% 76.2%
“Joint assessment at the
front door by the stroke Thrombolysis key indicators
team and A&E colleagues is
vital to ensure that patients Percentage of eligible patients (according to DGT 91.7% 95.2% 82.6% 92.3% 100.0%
are triaged to receive the the RCP guideline minimum threshold) given
thrombolysis National 74.3% 80.7% 84.9% 86.9% 87.8%
right treatment, first time.”
Dr. Tom Clark, Clinical
Percentage of patients who were DGT 30.3% 45.2% 42.1% 76.0% 59.8%
Director, PRUH thrombolysed within 1 hour of clock start National 53.2% 56.1% 58.5% 62.3% 63.7%
3
Background and context
Dartford and Gravesham has a clear action plan, a track record of
delivering improvements
Example elements of the Dartford and Track record of delivering improvements
Gravesham action plan:
• Support for SSNAP data collection Track record: creating a ring-fenced bed
• Improvement in % thrombolysed Results of introduction of ONE ring fenced bed in April 2018 to ensure the prompt
within 60 minutes transfer to the acute stroke unit. : Our direct admissions (total) has improved from all
• time low of 28% in Feb 2018 to 78% (April- July 2018)
Executive approval for ring fenced
bed
• Track record: driving up thrombolysis
Collaborative working with site
team, rehabilitation sites to ensure An improvement project with a focused approach analysing door to needle SSNAP
good patient flow data to increase the percentage of patients thrombolysed (where thrombolysis is
• Stroke specific discharge summary indicated) within 1 hour (golden hour); this project has been successful and
• sustained (evidenced in an increase in the percentage of patients thrombolysed
Monthly stroke data
within 1 hour from 30% in 2013/14 to 64% in 2-17/18)
Key risk: Payment of best Track record: an experienced team
practice tariff would still Clinical lead for stroke: DGT’s dedicated and driven service lead is an experienced
result in stroke being a loss- stroke consultant who has developed the DGT stroke service and led on DGT’s
making service for the Trust. service improvements, examples of which are outlined above
Both London and Head of Nursing: DGT’s HoN was a stroke CNS and then a lead stroke nurse,
! Manchester have
implemented top-up rates
providing clinical leadership and service development across Kent and Medway. She
was a member of the expert clinical review group at the request of the South East
for providers and we would Clinical Senate in 2016, and was previously member of the CRG for the K&M stroke
wish to explore this further review.
across Kent and Medway
General Manager: The DGT GM has previously supported delivery of two network
with our CCG commissioners.
stroke service solutions, one in Cambridge/ Peterborough and another in West Essex.
4
Background and context
Wider context to the provision of stroke services across Kent and
Medway
• Efficient patient flow across the system will be of paramount importance; this requires successful work with
partner organisations, including rehabilitation service providers
• Dartford and Gravesham commit to working with CCGs, Trusts and other partners across the region to ensure:
– Rehabilitation pathways and services are consistent across Kent and Medway
– All Kent and Medway HASU/ASU staff have the same competencies and training
– Patients from Bexley also follow the same standardised pathways, with efficient routes out to
rehabilitation services
– Standardisation is clinician-led across the region
Key risk: The stroke service consultation does not include rehabilitation services; this poses a risk to patient
flow from future HASU/ASUs. This needs to include the pathways into neuro rehab and nursing home beds. A
! lack of collaboration with the following partners would lead to difficulties in patient flow from DGT’s
HASU/ASU and/ or ED: Bexley CCG, Virgin Healthcare, non-HASU/ASU DGHs
Track record of collaboration: Vanguard with Guy’s and St Thomas’: Through their Vanguard, Dartford and
Gravesham and Guy’s and St Thomas’ effectively collaborated in three clinical programmes in paediatric
services, cardiology and vascular services. Over 1,100 patient appointments were held at DGT rather than
GSTT over the 18 month period of the programmes, improving the experience of these patients by providing
care closer to home and saving money within the local economy. The clinical programmes also supported the
upskilling of DGT staff, and there is qualitative evidence that this has improved recruitment and retention
5Overview of the options
There are three options under consultation in which Dartford
and Gravesham has a HASU/ASU
Under options
Current
Bed increase
HASU beds
number of
Total beds
ASU beds
Mimics
strokes
Number of
beds at
TIAs
DVH
Options
Option A:
Darent Valley Hospital
Options A and B are Medway Maritime 27 882 88 220 10 27 37 +10
comparable in scale Hospital
for DVH; deliverability William Harvey Hospital
is considered broadly Option B:
equal Darent Valley Hospital
Maidstone General 27 807 81 202 10 24 34 +7
Hospital
William Harvey Hospital
Option E is considerably Option E:
larger for DVH; Darent Valley Hospital
27 1,174 117 293 14 36 50 +23
deliverability challenges Tunbridge Wells Hospital
scale up for this option William Harvey Hospital
6Capacity
The deliverability of the HASU/ASU will be dependent on
ensuring capacity in a number of areas
Capacity constraint High-level view Page ref.
Medical beds The capacity of DVH has been modelled under
Capacity in medical beds across the organisation options A, B and E; in all cases sufficient capacity
8
Please note that the implementation plans are can be achieved. Please note that
provided on pages 16-20. interdependencies are further details on p. 21
The existing capacity constraint within the A&E
Capacity within A&E, resus and ITU department will be eased through the co-location
The increase in stroke service activity under of UTC services and other improvement work with
9
options A, B and E will increase activity in A&E ambulatory pathways. Additional resus capacity is
and resus, and may impact ITU. planned, and ITU is expected to be able to absorb
any small activity increase.
Radiology capacity
Existing on-site machines have sufficient capacity
The HASU/ASU will require radiology capacity 10
for all A&E, in-patient and future stroke patients.
for urgent patients.
Workforce Radiology clinical workforce remains a key risk for
A gap analysis has been completed to indicate all units across the region. Mitigations (workforce
the increase in workforce required under each engagement, planning) have been completed, 11-15
model. Leadership and project management although greater mitigation will be possible once
resource is also considered. the option decision is taken.
7Capacity: Medical beds
Additional medical beds will be provided through a modular unit
with the Local Care initiative considered in the long-term plan
• These numbers, which are the Modelled impact on medical bed capacity under a 92% occupancy rate
overall demand through
2020/21
2018/19
2019/20
2021/22
2022/23
2023/24
2024/25
2025/26
2026/27
population growth (including Current
Ebbsfleet), include the impact number of
of mimic and TIA patients beds
• They are gross numbers before Option A
the impact of Local Care, which Stroke adjustments - - - 10 10 10 11 11 11 11
is planned to reduce length of Beds needed 435 449 452 474 492 508 523 537 556 574
stay and avoid admissions in Shortfall of beds 0 -14 -17 -39 -57 -73 -88 -102 -121 -139
the medium-long term (see p. Option B
18) Stroke adjustments - - - 7 7 7 7 8 8 8
• They have been used to dictate Beds needed 435 449 452 471 489 505 520 534 553 571
the site plan (see Appendix B) Shortfall of beds 0 -14 -17 -36 -54 -70 -85 -99 -118 -136
to ensure sufficient capacity Option E
Stroke adjustments - - - 23 23 24 24 25 25 25
Key risk: The Local Beds needed 435 449 454 487 505 522 537 551 570 589
Care initiative may Shortfall of beds 0 -14 -17 -52 -70 -87 -102 -116 -135 -154
be unsuccessful in
reducing average Track record of delivering a LOS reduction: The average adult medicine non-elective length of
length of stay. This stay at DGT has reduced from 6.86 days (2016/17) to 5.48 (2017/18). A reduced length of stay is
! risk is to be mitigated
by the appointment
known to reduce infection rates and improve overall patient outcomes as well as patient
experience. The reduction has been achieved through a range of improvements such as:
of a joint Local Cate • The introduction of discharge-to-assess and the ‘red and green days’ programme
Programme Manager
• Weekly reviews of long stay patients (7+, 14+ and 21+ days)
between DGT and
• Increased focus through an IDT with social services to reduce detox delayed transfer of care
the CCG
8Capacity: A&E, resus and ITU
A&E, resus and ITU capacity has been considered; additional
activity can be absorbed or catered for within existing units
A&E
Key risk: The DGT A&E department, as
• Within the next 12-18 months the UTC (currently the minor injuries using with other Trusts across the region, is at
at Gravesend Hospital, walk in centre at Northfleet, and GP out-of-hours present stretched, with 88.6% of all
services) will all be co-located at Darent Valley Hospital with the A&E attendees seen within 4 hours in July
•
department
This will ensure more robust streaming of patients to the right services,
leaving A&E capacity for emergency patients including for HASU/ ASU
! 2018. As described, this risk is mitigated
through the various improvement
workstreams and the planned co-
• In addition, improvement work is ongoing (e.g. ambulatory care pathways, location of UTC services within Darent
Rapid Assessment and Treatment, etc.) Valley Hospital.
Resus
Track record delivering increased A&E
• Based on modelled activity, one additional resus bed will be created to activity: South East London closed its
support options A and B; this can fit without difficulty into the existing A&E and maternity units at Queen Mary
resus unit Hospital in 2010. DVH became the
• Two beds will be added for option E; whilst this requires more re- primary provider for the population of
organisation of the department it has also been successfully planned Bexley and the surrounding areas. A&E
• Both plans are provided in Appendix C 4-hour targets remained stable
ITU throughout. In 2013 South London
Healthcare Trust was dissolved; DGT
• DGT modelling undertaken evidenced sufficient capacity in our ITU for the took on numerous elective services for
population increase and any increase from a model change Bexley and the surrounding areas. Zero
• The bed capacity modelling will support improvements in patient flow patients were lost, harmed or
• Learning from the London implementation suggests that capacity is inconvenienced through the transfer,
needed to support patients who have been in ITU and who require evidencing a track record of well
tracheostomy management within the stroke ward, as opposed to within a managed, large scale transformation.
respiratory pathway. This will require the upskilling of nurses (see p. 12).
9Capacity: radiology
Radiology capacity is not considered to be a risk given DGT’s
existing on-site capacity
• Dartford and Gravesham operates four major scanners:
– Two CT at Darent Valley Hospital Key risk: Should one of the two on-site
– One CT at Queen Mary Sidcup scanners break, this could cerate a risk by
– One MRI at Darent Valley Hospital which the Trust has one scanner to meet
– Additional MRI capacity is available through Alliance the needs of A&E and the HASU/ASU.
Medical at Queen Mary Sidcup ! However, given the investment into a new
machine for September 2018 and the
• The CT scanner at Queen Mary Sidcup currently has three presence of two on-site machines, the risk
unused sessions within a 9am-5pm working week, and is not to patients is perceived to be low.
used during evenings; additional elective activity currently
completed at DVH could therefore be moved to Queen Mary
Sidcup
Track record: Working with partners to
• As DGT has access to flexible volumes of MRI capacity for drive innovation
ambulatory patients, there is no anticipated risk regarding Through the Healthcare Alliance, DGT is
on-site MRI capacity working with Guy’s and St Thomas’ to drive
•
innovation in radiology reporting. This
Therefore, there is sufficient on-site capacity for all
workstream aims to release overall capacity
expected additional CT and MRI activity from both
in the system through standardisation and
population growth and the implementation of a HASU/ASU
by enabling remote reporting at each Trust.
under options A, B and E
This collaboration is an example of DGT
• Learning from London would suggest a three-way bleep, actively looking for areas of future capacity
including a radiographer, stroke nurse and stroke consultant, constraint to pro-actively manage them.
in order to access CT/ CT angiograms, would be beneficial
10Capacity: workforce
A gap analysis has been completed of the workforce
requirements under the three models
In post 30th Required for TUPE from Options A and B require
Staff group Gap Revised Gap
April 2018 HASU/ASU other units significant recruitment.
Option A For option E the level of
Consultant 1.00 7.10 6.10 1.12 4.98 recruitment is further
Nurses (reg. and unreg.) 32.80 66.01 33.21 6.84 26.38 scaled up, which poses a
Scientific, Therapeutic & Technical 8.30 20.05 11.75 4.37 7.38 proportionally higher risk.
Stroke co-ordinators, healthcare - 7.00 7.00 - 7.00 In addition, the
assistants and administration movement to a full 7-day
Option B
supporting radiology
Consultant 1.00 7.10 6.10 1.48 4.62 service will require
Nurses (reg. and unreg.) 32.80 61.40 28.60 7.06 21.54
additional requirement
Scientific, Therapeutic & Technical 8.30 18.42 10.12 4.79 5.33
Stroke co-ordinators, healthcare - 7.00 7.00 - 7.00
Assuming a TUPE of 6.68
assistants and administration
Option E
WTE nurses from closing
Consultant 1.00 7.10 6.10 1.39 4.71
units, option E would
Nurses (reg. and unreg.) 32.80 87.87 55.07 6.68 48.38 require the recruitment of
Scientific, Therapeutic & Technical 8.30 26.36 18.06 5.86 12.20 48.38 WTE nurses, of
Stroke co-ordinators, healthcare - 7.00 7.00 - 7.00 which 38.02 are registered
assistants and administration
Key risk: Further work needs to be undertaken to ensure that sufficient non-patient contact time has been included for all staff
! groups.
Key risk: The gap analysis shows a large gap in typically difficult-to-recruit groups, which poses a material risk.
•
! •
More information on recruitment and training as a mitigation is on p. 12-13
More information on staff engagement as a mitigation is provided on p. 14
11Capacity: workforce
A recruitment and training plan is set out to meet the needs of a
HASU/ASU at Darent Valley Hospital
• Recruitment of staff is a critical success factor; a recruitment and training plan is outlined on p. 13
• DGT is committed to ensuring recruitment is sustainable at a system-wide level; recruitment to the HASU/ASU will not destabilise other
Trusts
– Recruitment will be through multiple routes, including staff from closing stroke units within the region, staff from outside the region,
and newly-qualified staff
– In particular, DGT has established strategies for local, national and international nurse recruitment
– DGT will also work with partners in London, as it does with GSTT through the Healthcare Alliance, to offer an attractive care er
progression model to retain staff within the NHS
– DGT has existing strong relationships with local universities providing newly-qualified staff
• In order to build system-wide capacity, training will be prioritised:
– HASU/ASU training, including tracheostomy management, will be provided by current medical, nursing and therapy specialists; D GT
benefits from the presence of a Caroline Bates, the Head of Nursing for Emergency and Adult Medicine, who has significant
experience as a specialist within stroke
– Learning from the London implementation would suggest a key role for a pathway coordinator, at least weekly education meeting s,
and links to a nurse consultant could be of significant benefit across the network
– DGT will support the development of the stroke clinical network with shared regional competencies
– DGT will also look to access expertise from the South East London Cardiovascular network
• DGT currently works with psychologists employed by KMPT, and so there is no risk to increasing capacity for this group
• In order to mitigate day 1 risk, the existing in-house bank will be bolstered to ensure sufficient capacity
Key risk: The proposed staff numbers are Track record of innovative workforce design: Doctor Assistants
subject to sensitivity analysis; there is a risk that Support doctors with admin tasks, reducing doctor time spent on
! under a more conservative model the numbers
could increase. This poses a particular risk under
option E
administration and resulting in more time spent on patient care. They have
also improved consistency with medical notes, and help to coordinate the
process of completing electronic discharge notifications
12Capacity: workforce
The chart below outlines the key activities planned to
ensure the HASU/ASU is safely staffed for success
Decision
09/18
10/18
11/18
12/18
10/19
11/19
12/19
2/19
7/19
1/19
3/19
4/19
5/19
6/19
8/19
9/19
Activity
Recruitment
Engage staff at closing units
Engage universities
Recruitment drive
Training
Standardisation of competencies
Training of stroke staff to competencies
Specialist training
Leadership
Set the Executive SRO
Procure project management resource
Leadership improvement skills training
Staff, public and patient engagement
Go/ no-go review for safe handover
Post-transfer review process
These activities will run in parallel to the implementation programme, as outlined on p. 17 and within Appendix D
13Capacity: workforce
All DGT staff have been engaged throughout the consultation
process through a variety of means
Examples of staff engagement through the Key risk: Throughout the consultation there is a risk that
consultation process stroke staff are lost across the system to other regions or
• The STP newsletter and information from the
Healthwatch has been shared with all staff ! services due to uncertainty. This is being mitigated through
workforce engagement.
• Staff have been involved in the Clinical
Reference Group
• Staff engagement workshops have taken place Key risk: In setting up the HASU/ASU, DGT will be looking to
which representatives from all therapist recruit staff from closing stroke services. However, this will
groups have attended rely on ensuring an attractive offer (for example, through
• leveraging the Healthcare Alliance relationship with Guy’s
Two therapist leads have alternated
attendance at the STP stroke consultation ! and St Thomas’ for leadership development and
opportunities). In addition, the limited planning period of
workforce group
double running could present a situation in which new units
• The lead stroke physiotherapist has attended must open before the closure of existing.
the rehabilitation workstream throughout the
consultation
• Feed back on progress has been provided in “When the Senior Physiotherapist does attend meetings
the monthly stroke meetings regarding the service, she is very good in relaying the
• The DGT CEO has met with stroke staff to information back to her staff. I understand why services are
discuss the consultation being re-designed, and am reassured that each staff member
• All staff have been made aware of upcoming is going beyond their way in caring for patients.”
workshops being held by the STP on the Band 6 rotational physiotherapist, DGT
consultation
14Capacity: workforce
Leadership and project management capacity for the
implementation of the HASU/ASU is also identified
Senior Responsible Officer
• Director of Improvement, will be the SRO for the implementation of the HASU/ASU
• SRO responsibilities for major programmes are divided across the Executive team to ensure focus
Clinical Director
• DGT has recently recruited Jonathan Kwan as the Clinical Director for the Emergency and Adult Medicine
Directorate. Jonathan has previously been involved in the London stroke review and was the Medical Director at
Epsom St Helier during its implementation.
Project Management
• DGT is currently implementing a new project management approach across the Trust which will be in place for
HASU/ASU delivery. This will also draw on the expertise of GSTT through the Healthcare Alliance.
Key risk: The Local Care initiative may be Track record of delivering a major project:
unsuccessful in reducing average length of stay,
A&E redesign: Maintaining a safe service during a major
which would pose a risk that the modular unit
extension to the emergency department, providing
would not be removed within three years as
! planned (see p. 18). This risk is to be mitigated
by the appointment of a joint Local Cate
essential capacity to the emergency workstream through
a c. £4m investment
Programme Manager between DGT and the GP streaming: ED maintained operational while
CCG. reconfiguring entrance to implement two new GP rooms
15Implementation
The implementation poses a number of potential
risks to deliverability, all of which are being managed
Implementation consideration High-level view Page ref.
DM Business Case / Selection – 13th Sept 2018
Trust Business approved - 19th Dec 2018
Timeline/ implementation plan
Planning approval - 28th Feb 2019 17
and go-live date Funding available - 08th Apr 2019
Works Complete, HASU open 13th Dec 2019
Architectural drawings
Plans to accommodate the beds for the 3 options for DVH have
Please note that detailed
been developed and are included in Appendix B. Further 18
drawings are provided within
detailed design will be undertaken on the preferred option.
Appendix B
At PCBC a capital requirement was estimated for DGT based on
initial scoping of the three options. Since this stage, further
Capital requirements development of the plans has demonstrated that Options A and 19
B remain within this estimated capital requirement, whereas
Option E is now above the PCBC estimate.
Risks associated with key mobilisation activities are being, or will
Key mobilisation activities
be as appropriate, actively managed to ensure successful 20
(including planning permission)
delivery.
16Implementation: Timeline/ implementation plan
The simplified Gantt chart below sets out the timeline
for earliest completion and hence earliest go-live date
Decision
09/18
10/18
11/18
12/18
10/19
11/19
12/19
2/19
7/19
1/19
3/19
4/19
5/19
6/19
8/19
9/19
Activity
DM Business Case (Selection and approvals)
Trust Full Business case (Equivalent)
Ward costing
Modular Unit costing
FBC (equivalent)
Local Authority Planning
Works (Sequential, Modular and Internal)
Modular Unit works
Ward works
Commission DVH HASU / ASU
Appendix D provides further detail regarding the implementation programme; for more information
regarding the recruitment and training plan, see p. 13
Key risk: Only two months of double running have been budgeted for; this suggests a need for units to
! open/close within a tight time scale. The above Gantt sets out the provisional time scale leading to the earliest
go-live date, but is adjustable to mitigate this risk.
17Implementation: Timeline/ implementation plan
Draft drawings have been worked up for options A, B
and E; these will be iterated as the process progresses
• In order to ensure sufficient capacity across the Trust, the HASU/ASU will be created through re-
development of an existing ward (adjacent to the current stroke unit). Space has been allocated, both to a
TIA clinic area and to a TIA assessment area following learning from the London implementation.
• A modular unit will be leased for three years to provide the additional required capacity, as dictated by the
activity planning (see p. 8). During these three years the Local Care initiative will reduce admissions and
the average length of stay; DGT’s track record in reducing length of stay is also described on p. 8.
• DGT has already commissioned the development of plans for the HASU/ASU under options A, B and E,
which are provided within Appendix B. These plans are well advanced, ensuring that mobilisation activities
can be completed pro-actively with the timeline remaining flexible to minimise double-running (see p. 17).
Key risk: Option E does not provide further room for future growth within the existing space and no
! flexibility within the model. Any growth would require a new build.
Track record of delivering: Internal beds Track record of delivering: Heart Centre
A c. £2.5m investment was made over two The Trust has undertaken major new builds on
years to remove non-clinical functions from the site. The Heart Centre was commissioned
inside the ward environment, creating 25 and build on the site. The Heart Centre was
additional beds. This involved reconfiguring built on the Hospital site, attached to the
wards whilst maintaining the safe operation of building.
normal clinical services.
18Implementation: Timeline/ implementation plan
Options A and B remain in line with the PCBC DGT
capital estimate
• At PCBC a capital requirement was estimated for DGT based on initial scoping of the three options
• Since this stage, further development of the plans has demonstrated that Options A and B remain within
this estimated capital requirement, whereas Option E is now above the PCBC estimate
Capital requirement (£ ‘000s)
Option A Option B Option E
Item
Works subtotal (beds and resus bay requirements) 314 241 1,137
Fees 79 60 284
Equipment costs 47 36 171
Non-works 5 4 17
Planning contingency 45 34 161
Optimism Bias 127 97 458
VAT 107 83 389
Total 723 556 2,617
Key risk: The capital envelope was set at PCBC stage. However, the plans will be further developed as part
! of the full business case completion and there is a risk that the capital requirements grow. Contingency
and optimism bias has been factored into the capital cost in order to mitigate this risk.
19Implementation: Timeline/ implementation plan
Key mobilisation activities have been considered and
will be completed pre-emptively where possible
Key mobilisation activity
! Perceived risk Mitigation
Trust met Planning Authority and progressing
Planning delayed due to limitation
Establishing planning presentation to the Development Committee
on permissible development and
permission and preparing car park expansion proposals for
car parking at the hospital site
submission to the Local Authority
Estates Capital lead has met Local Planning leads
Discharging planning Delay in discharging Planning and will maintain dialogue to communicate the
conditions conditions Stroke proposal and benefit to the Dartford
Community
Initial meeting progressed with supplier. Early
Procurement of modular Delay in design and delivery of the
design and procurement planned if selected as
unit Modular Unit
preferred option
Trust informed PFI Partner of Stroke
Conclusion of the contract Delay in signing-off PFI Contract
Consultation. Plans to accommodate Stroke in
variation document documentation
Hospital site to the PFI Hospital Directors
20Other considerations
There are a number of interdependencies which will materially
impact DGT’s ability to deliver the HASU/ASU
Interdependency Management approach
External
stakeholders
• The most critical factor for ensuring smooth patient flow through the
Patient pathways into HASU/ASU will be the pathway into rehabilitation CCGs
rehabilitation • DGT has substantial and successful experience working in collaboration with Virgin Care
partner organisations, including in co-designing patient pathways
Patient pathways for • DGT recognises the need to support a commissioner decision as to the
Non-HASU/ASU
patients identified as non- pathway for patients presenting at a HASU/ASU who are determined to be
stroke DGHs
non-stroke
• As described on p. 18, a reduction in the average length of stay is expected to
CCGs
be delivered through the Local Care initiative; this will allow for the removal of
Local Care implementation Primary and
the modular unit within three years
community care
• A joint lead has been appointed between DGT and the CCG
• DGT will support a regional approach to workforce development, including
System-wide workforce
requirements aligned recruitment strategies and a shared competency framework All NHS Trusts
• DGT holds strong relationships with universities
• Within the consultation process, the Dartford DA postcode area produced the
System-wide public
highest number of responses from the public to the consultation1
engagement • However, in order to reassure the public and ensure the services are used All organisations
effectively, the public across the region must be engaged with a consistent
message and in a pro-active way
21
Source: 1. Stroke CRG May 2018 minutes“We are committed to working hard to see these changes implemented in the most effective way over the next
couple of years and would do everything we could to get the new service up and running as quickly as possible. We
can act quickly because our service model is based on immediate refurbishment, which also provides a cost effective
solution.”
Gerard Sammon Peter Coles
Interim Chief Executive Chairman
22
23Appendix A
Risks and mitigations
Risk Mitigation Page ref.
The stroke service consultation does not include rehabilitation services; this poses a •
Existing strong relationships with providers across the
risk to patient flow from future HASU/ASUs. A lack of collaboration with the following
region 5
partners would lead to difficulties in patient flow from DGT’s HASU/ASU and/ or ED:
• A strong track record of collaboration
Bexley CCG, Virgin Healthcare, non-HASU/ASU DGHs
• This risk is mitigated by the appointment of Sue
The Local Care initiative may be unsuccessful in reducing average length of stay. 8
Braysher as joint lead between DGT and the CCG
The DGT A&E department, as with other Trusts across the region, is at present • This risk is mitigated through the planned co-location
9
stretched, achieving 88.6% of all patients seen in less than 4 hours in July 2018. of UTC services within Darent Valley Hospital.
• This risk is mitigated by the investment into a new CT
Should one of the two on-site CT scanners break, this could create a risk by which the
scanner for September 2018 and the presence of two 10
Trust has one CT scanner to meet the needs of A&E and the HASU/ASU.
on-site machines.
• This risk is mitigated through:
The gap analysis shows a large gap in typically difficult-to-recruit groups, which poses•
A recruitment and training plan, outlined on p. 12-13
a material risk. • Engagement of the existing workforce, outlined on p. 11
14
The proposed staff numbers are subject to sensitivity analysis; there is a risk that
under a more conservative model the numbers could increase. This poses a particular • As above 12
risk under option E.
Throughout the consultation there is a risk that stroke staff are lost across the system • This risk is mitigated through engagement of the
14
to other regions or services due to uncertainty. existing workforce
In setting up the HASU/ASU, DGT will be looking to recruit staff from closing stroke
services. However, this will rely on ensuring an attractive offer. In addition, the • This risk is mitigated through the recruitment plan, as
14
limited planning period of double running could present a situation in which new outlined on p. 12-13
units must open before the closure of existing.
The Local Care initiative may be unsuccessful in reducing average length of stay, • This risk is mitigated by the appointment of Sue
which would pose a risk that the modular unit would not be removed within three 15
Braysher as joint lead between DGT and the CCG.
years as planned.
24Appendix A
Risks and mitigations
Risk Mitigation Page ref.
Only two months of double running have been budgeted for; this suggests a need for • The programme timeline and plan is adjustable to
17
units to open/close within a tight time scale. mitigate this risk.
Option E does not provide further room for future growth within the existing space •
n/a 18
and no flexibility within the model. Any growth would require a new build.
The capital envelope was set at PCBC stage. However, the plans will be further developed • Contingency and optimism bias has been factored into
19
as part of the full business case completion. the capital cost in order to mitigate this risk.
• Trust met Planning Authority and progressing
Planning delayed due to limitation on permissible development and car parking at the presentation to the Development Committee and
hospital site
20
preparing car park expansion proposals for submission to
the Local Authority
• Estates Capital lead has met Local Planning leads and will
Delay in discharging Planning conditions maintain dialogue to communicate the Stroke proposal 20
and benefit to the Dartford Community
• Initial meeting progressed with supplier. Early design and
Delay in design and delivery of the Modular Unit 20
procurement planned if selected as preferred option
• Trust informed PFI Partner of Stroke Consultation. Plans
Delay in signing-off PFI Contract documentation to accommodate Stroke in Hospital site to the PFI 20
Hospital Directors
25Appendices B, C and D
See separate documents
Appendix Description
Architects drawings for medical beds:
Page 1: Modular unit for three years of additional capacity
Appendix B Stroke
Ward Estates Plan
Page 2: Option A HASU/ASU layout
Page 3: Option B HASU/ASU layout
Page 4: Option E HASU/ASU layout
Architects drawing for one additional resus bed within the existing department, in
line with Option A and Option B.
Appendix C Stroke
Resus proposal Please note: Option E requires two additional resus beds. Whilst a drawing of this
has not been commissioned at this time, the architect has stated that this will be
possible within the existing unit using a similar design at the other end of the unit.
Appendix D Detailed Detailed programme Gantt chart for the implementation of the HASU/ASU (physical
programme Gantt chart site implementation)
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