South Warwickshire NHS Foundation Trust

Report to Board of Directors – 1 July 2015

Right-Sizing Plan

Executive Opinion This paper reflects on the Trusts capacity plans and considers the opportunity provided by the new ward accommodation, to ensure we make best use of the estate to support the on-going provision of safe services. It is a valuable document that the Board can use to underpin investment decisions to ensure capital is invested wisely. It is always a difficult and contentious exercise, and needs to be carried out at a corporate level without the distraction of local preferences and priorities. However, it does rely on intelligence gathered from considerable consultations across a wide range of stakeholders. The current plan provides the Board with a strategic road map and in addition provides assurance that the benefits within the new ward business case are being delivered i.e. 1. We are creating a centre of excellence for orthopaedics 2. Providing space to support the reconfiguration other specialties to meet demands

(right-sizing) and develop services (such as Emergency Assessment, and Maternity services)

3. We are creating an opportunity to generate additional surplus It highlights a number of key risks: 1. Elective Bed capacity – the Division continues to work on their bed configuration to

ensure maximum efficiency. 2. Workforce – The Trust continues to have significant work force issues in a number of

key areas such as Care of the Elderly and providing a flexible workforce to support additional capacity at times of high pressure

3. Funding – Although the Trust has improved opportunities to increase bed capacity or develop new services, this will depend on affordability by Commissioners

The next steps will include: • Develop detailed operational plans for next 12 months • Design Emergency Assessment area and final A&E configuration • Develop new Maternity 5 year Plan Jayne Blacklay Director of Development

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

Meeting Board of Directors

Date 1 July 2015

Subject Right Sizing Plan Enclosure E

Nature of item For information For approval For decision

Decision required (if any)

The Board of Directors is asked to approve this document as the first iteration of the Right Sizing Plan and the actions identified take place alongside the on-going development and refinement of the plan.

General Information

Report Author Fiona Langworthy – Head of Business Development Lead Director Jayne Blacklay – Director of Development

Received or approved by

Meeting Management Board Date 26 June 2015

Resource Implications

Revenue Capital Workforce Use of Estate Funding Source

Applicable Quality Improvement Priorities

Care Quality Commission Rating Nurse Staffing Levels Paperless Working Electronic Requesting Food Delivery Dementia Complaints Feedback

Freedom of Information

Confidential (Y/N) (if yes, give reasons)

No

Final/draft format

Final

Ownership

Trust

Intended for release to the public

Yes

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South Warwickshire NHS Foundation Trust

Report to Board of Directors – 1 July 2015

Right Sizing Plan

Executive Summary Over the years, the Trust has experienced growth in demand driven by demographic changes in our catchment area which has resulted in increased pressure on inpatient capacity and resources. As part of both the Emergency Pathway Work and Estate Development Plan, the ‘Right Sizing Plan’ looks at how we can right-size specialties so that capacity is available on a sustainable basis to meet specialty demand. It is anticipated that this plan will support specialties to understand demand growth projections for the future to identify how they should configure themselves to respond. In effect, the Right Size Plan is an Estates Plan. It underpins the Capacity Plan and has been developed to outline our capacity requirement by area/specialty for the next 5 years and to document the assumptions we have made about changes to demand and service delivery. The document is aligned to all capacity planning work undertaken thus far and uses the same data and planning assumptions. A wide range of stakeholders (clinical, nursing, allied health professionals and managerial staff) have been involved in supporting and developing the Plan and timetable (see on page 8) – this has been key to understanding what the issues are and what the reconfiguration of wards can do to improve or remove these problems, as well, as create buy-in from staff. During the process of gathering information from staff it is clear that no one reconfiguration plan fits perfectly and resolves all pathway flow issues. However, what the Plan has done is ‘listen’ to staff comments and proposed a configuration plan that makes best use of accommodation now and in the future. A key point of the Plan was to reassure the Board that decisions and actions made in the short-term did not affect what the Trust plans to do in the long-term; the timetable and plans outlined in this document confirm this to be the case including reassurance that the changes are financially prudent. In summary, the Right Sizing Plan provides an estates plan that delivers the capacity required over the next 5 years. Using the data and information provided, the Plan provides both a short and long-term plan and considers all specialties (adult) by admission type. Overall, the development of the new ward block provides the Trust with further space to cope with increased demand over the next 5 years. This is very reassuring, however, there are a number of interdependencies such as workforce (ability to recruit) and changing models of care which are key to ensuring we can continue to provide adequate inpatient capacity to meet demand. These interdependencies must not be underestimated when planning for the future. Details of how the extra space could be utilised in the short-term will be included in the Operational Winter Resilience Plan due at the end of July 2015.

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The Right Sizing Plan will continue to develop over the 5 years and be subject to the same review and scrutiny as the current plan has undergone. The Plan will be updated and presented to the Board on a yearly basis.

Recommendations

The Board of Directors is asked to approve this document as the first iteration of the Right Sizing Plan; further updates will be provided as time progresses and plans develop. It is recommended that the following actions take place alongside the on-going development and refinement of the plan: • The right-sizing and reconfiguration of specialties continues to progress to ensure

service and capacity provision is deliverable in the short and long-term. Initial focus will be on the issues raised in this document and will be included in the Operational Winter Resilience Plan.

• Service delivery teams confirm the risks and achievability of the reconfiguration timetable presented; − Development of business cases as outlined in the timeline: Mid wife led unit Front door redesign – Emergency pathway CERU Phase 4 Other vacated areas created through the New Ward Block opening

− Further service developments identified – on-going and iterative process.

Fiona Langworthy Head of Business Development

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South Warwickshire NHS Foundation Trust

Report to Board of Directors – 1 July 2015

Right Sizing Plan – 2015/16 to 2019/20 Background Underpinning the ‘Capacity Plan’ is the ‘Right Sizing Plan’ which reviews current ward accommodation and considers utilisation of accommodation for the future that better fits the demand by specialty area. The Trust has an excellent opportunity in December 2015 when it opens three new ward areas and creates space elsewhere to potentially move ward areas and improve patient specialty flow. The Right Sizing Plan builds on from the: • Capacity Plan Report to Board of Directors 2013/14 to 2015/16 • Operational Capacity Plan 2014/15 • Operational Capacity Plan 2015/16 • Refreshed Capacity Plan 2015/16 (beginning of July 2015) • Operational Winter Resilience Plan (end of July 2015) The Capacity Plan Refresh will be presented to the Board of Directors and will provide a ‘look back’ on the changes in demand and capacity utilisation over the past 12 months. Using this information provides an opportunity to take stock of the current available ward footprint and plan for the future; this is vital to ensure we are in a strong position to manage, as efficiently as possible, increasing demand on hospital services. The Operational Winter Resilience Plan will be presented at the end of July to the Board of Directors. It dovetails well with the Right Sizing Plan and, together, future proofs the Warwick Hospital site both in the short and long-term. Scope The Right Sizing Plan is solely focussed on acute inpatient capacity requirements for the future. The plan includes admitted activity for all specialties by admission type (Elective, Emergency, Maternity and Other). The scope includes a: • Short-term, 1 year plan • Long-term, 5 year plan The Plan is multifaceted and involves understanding the interdependencies that impact on each other in the delivery of an inpatient service: • Workforce; • Estates – ward accommodation; • Models of care / pathways – current and future; • Information Technology advances, and • Financial drivers.

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The plan does not include detailed capacity requirements for diagnosis and treatment of admitted patients such as radiology equipment and theatres, however, the plan makes reference to the capacity constraints in both Radiology and Theatres and has been mindful of this when planning for the future. Approach - Key Considerations The approach of the Right Sizing Plan work has been to ask the initial question: What are we trying to solve? With further challenging questions: • Is there a requirement to change/rearrange the current accommodation footprint? • Are there clinical or operational changes to pathway/s that would be enhanced? • What difference does the move make – are there measurable outcomes? • Does the move create a pressure / issue elsewhere? • Does the move create a staffing issue? For example, split ward / requirement for staff

to be trained in other work • Is the move cost small i.e. little infrastructure cost? • Does the change / rearrangement affect what we do in the future? (key question) Stakeholder Engagement Key to the success of the Right Sizing Plan has been the approach taken in garnering the views of members of staff. It has been essential to involve a wide range of stakeholders to test and inform the assumptions made, particularly those members of staff who operationally are at the ‘coal face’. Meetings and interviews have taken place with clinical, nursing, allied health professionals and managerial staff to gain an insight and understanding of what is important to them and why. Together, the key priorities of the elective and emergency divisions (appendices 1 and 2) and the soft intelligence (appendix 3) along with hard facts on the bed numbers required over the next five years provides a rich source of information and enables a number of options to be considered in the short and long-term. Current Assumptions As already noted in the capacity plan, part of the plan’s development included a refined original model to incorporate different assumptions which better reflect local demand for healthcare. The growth and capacity requirements were calculated using the 2014/15 activity data as a baseline for admission rates and length of stay by admission type and age group. There are a number of assumptions the Trust has considered within the bed modelling work: • Demographic Growth; • Ageing Population, and • Health Improvement.

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The plan does not assume any additional health improvement beyond that which has already been achieved during the baseline year of 2014/15. We have not factored in any reduction in demand for healthcare by age group based on increased disability free life expectancy assumptions due to the lack of evidence to support reduced morbidity amongst our ageing population. Market Forces We have assumed no change to our current market share in this plan although work has already taken place to quantify the impact of market share growth in the Stratford locality. Occupancy Capacity calculations do not take into account aspirations to reduce occupancy levels and do not reflect variation in seasonal demand, resulting in a “smoothing” of capacity requirements across the full year (please note, bed requirement ranges have been included for information). That said, where we know we have significant seasonal variation, for example, in respiratory medicine, we have considered the high bed demand usage to ensure the Right Size Plan provides an optimum speciality configuration now and in the future. Emergency bed requirements have been calculated over 365 days, however, elective bed requirements have been calculated on the assumption that capacity is only available 5 days of the week, i.e. 252 days per year. Other factors which impact on the bed requirements for the future are also considered in the overall plan, for example, infection outbreaks.

• Service Delivery Models - Changes to service delivery

− Front door redesign for emergencies; − 7 day service delivery; − Ward standard processes; − Discharge to assess pathways 1,2 and 3; − Community productivity improvement; − Trauma Pathway; − Specialty Pull; − Medical Specialties - Respiratory & Cardiology; − TTOs; − Hospital @ Night, and − Outpatient Parental Antimicrobial Therapy (OPAT).

We have not assumed any further service delivery model changes other than what was already in place when the bed requirement activity figures were applied. However, we know the projects outlined above will reap benefits for the Trust, with some, releasing beds in the process. Taking a pragmatic and conservative approach, we are not assuming beds will close, but be utilised more efficiently to cope with the increased demand. The Trust is continuing to be more exploratory in how and where patients can be treated – focusing on discharging patients earlier and treating them closer to home / at home. Being treated at home is a significant improvement to patient care and it also allows the Trust to increase the bed turnover / utilisation, making best use of currently funded bed stock. The Trust is mindful, however, that the move of care out of the Trust must always make financial sense or be prepared to consider a financial risk sharing arrangement with key stakeholders.

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The aspiration of the IT strategy is to have a Trust-wide Electronic Patient Record that provides a single source of accurate information for patients. Acting as a significant enabler to change the way in which the Trust provides services and care for patients, the overall intent for inpatient activity (acute and community) is: • To provide a single joined up source of accurate electronic patient records; • To capture, use, manage and share electronic patient information and records more

effectively; • To reduce the complexity of the Trust application architecture, introducing new and

integrated clinical functionality i.e. Clinical Documents, Static Care Plans, Electronic Requesting, TTO & Outpatient Prescribing;

• To maximise the use of data collected to inform decision making from strategic to operational level, and

• To support the enhancement of capability and capacity within key workflows. • To use Lorenzo solution to support the Trust’s strategic theme:

− Improve bed management as functionality is not currently used in PAS; − Improve process of production of discharge summaries / letters; − Reduce cancelled operations and vacant outpatient slots; − Implement the Patient Safety Programme - Reduce falls within the Trust, and − Implement the Change Programme to deliver cost effective patient pathways across

hospital and community services. There has been careful consideration of the impact ward reconfigurations may have on overall IT strategy and IT projects. The IT strategy is seen as an enabler of improved efficiency in services and aligns well with the Right Sizing Plan. As IT programmes of work are deployed over the next 5 years, benefits will continue to be demonstrated further supporting and improving bed stock utilisation. Bed Requirement – Current and Future The future bed requirements for Elective and Emergency between now and 2019/20 are shown below. The elective bed requirement is based on a 5 day service delivery and proposes no further change to service delivery or current length of stay for bed requirements in 2019/20. Due to the seasonal variation seen in emergency work the specialty figures have been shown as an average based on 93% occupancy level and split by the first half of the year and the second half of the year to demonstrate seasonal variation.

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Elective Division – Bed Requirement

Elective Division - Bed Requirement

2014/15 2019/20 ** Based on Average +1SD

Trauma 35 40 Orthopaedics* 17 19 Elective Surgical Specialties* 21 23 Emergency Surgical Specialties 42 46 Total - Elective Division 115 128

* Assuming 5 day service delivery ** Projection based on 14/15 Age specific utilisation rate and demographic change projections (i.e. no change to service delivery models or current length of stay)

Emergency Division – Bed Requirement

N.B. Emergency activity split by first and last 6 month period to show seasonal variation. Observations • As in previous years, we’re seeing the same seasonal variation • During 14/15 (to Month 10), emergency admissions’ midnight bed occupancy ranged

from 256 to 380 beds • The average emergency admissions’ bed occupancy was 317, however, at least 10

additional beds were occupied for 35% of the time • Elective admissions’ bed occupancy is relatively stable • Demographic change between 14/15 and 19/20 is equivalent to an additional 10 beds

per year

Average based on 93%

occupancy

Q1-2 Average based on 93%

occupancy

Q3-4 Average based on 93%

occupancy

Average based on 93%

occupancy

Q1-2 Average based on 93%

occupancy

Q3-4 Average based on 93%

occupancyRespiratory (D codes) 60 49 72 69 56 83Circulatory (E codes) 30 34 27 34 39 31Genito Urinary (L codes) 30 28 32 35 32 37Gastro/Hepatobiliary (F&G codes) 32 37 29 37 43 33General 18-74 38 36 38 40 38 40Elderly >75 60 59 60 71 70 71Stroke (A22, A23 & A29) 9 8 10 10 9 11Paediatrics 11 9 12 10 8 11Babies 22 21 23 22 21 23Maternity 24 24 25 25 25 26Total - Emergency Division exc Paeds, Babies & Maternity 259 251 268 296 287 306

Total - Emergency Division 316 305 328 353 341 366

2014/15 2019/20Emergency Division - Bed

Requirement

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Current Ward Areas and Future Ward Areas - Bed Numbers

AREA Beds / Chairs AREA Beds / Chairs

A&E Observation Unit 5 A&E Observation Unit 5Ambulatory (chairs only - not counted) 6 Ambulatory (chairs only - not counted) 6Sub Total 5 Sub Total 5

Fairfax ward 30 Fairfax ward 30Avon ward 22 Avon ward 22Castle ward 25 Castle ward 25Coronary Care Unit 9 Coronary Care Unit 9Charlecote Ward 21 Charlecote Ward 21Farries Ward 22 Farries Ward 22Malins Ward 20 Malins Ward 20Mary Ward 25 Mary Ward 25Nicholas ward 20 Nicholas ward 20Oken Ward 15 Oken Ward 15Squire Ward 20 Squire Ward 20Victoria Ward 21 Victoria Ward 21Sub Total 250 Sub Total 250

23 hour ward 18 23 hour ward 18Beaumont ward 18 Beaumont ward 18 beds to maternityGuy Ward 27 Guy Ward 27Hatton Ward 20 Hatton Ward 20Willougby Ward 27 Willougby Ward 27Sub Total 110 Sub Total 92Total Beds including observation beds 365 Total Beds including observation beds 347

Dugdale - community 18 Ground floor ward 22Total Beds including Dugdale 383 1st floor ward 20

2nd floor ward 15Dugdale 18Sub Total (excluding 2nd floor & Dugdale) 42

Total (inc obs & excluding 2nd floor) 389Total (including obs & 2nd floor) 404Total (including obs, 2nd floor & Dugdale) 422

SPARE CAPACITY

A&E ASSESSMENT & AMB SHORT STAY

MEDICAL

SURGICAL

NEW WARD BLOCK & DUGDALE

A&E ASSESSMENT & AMB SHORT STAY

MEDICAL

SURGICAL

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For further reference, please see enclosed plan of ward layout.

In the plans for the Trust, the new ward block (Ground floor (22), First floor (20), Second floor Amenity (15)) will provide an additional 12 beds overall. However, if the vacated space is also included, potentially a further 27 beds (Guy ward) are provided – this assumes Beaumont ward develops into a midwife led unit (business case pending) and Dugdale ward is never used again as a community ward/extra winter contingency area. This extra space (27 beds) is unfunded, however, it provides the Trust with additional accommodation should it be required during periods of peak activity - winter. It must be emphasised at this point that the new ward block creates over provision of elective beds and there is a clear expectation and requirement that current bed stock must be utilised efficiently and, where necessary, allowing other specialties access to use of these beds. The bed management policy currently being revised will include decision making of how and when beds will be used and managed across the site – this will include the utilisation of elective beds by other specialities if and when required , without impacting on elective flow. In summary, the new ward block supports a number of ward reconfiguration options in both the short and long-term and the Trust is keen to exploit this opportunity to get it right, now, and in the future, aligning specialties / pathways in the most advantageous way possible.

Guy

27

A&E & Observation

(5 obs, 13 cub, S&T 4)

Oken

15 (inc 6 GAU)

Beaumont

18

Fairfax

30

Nicholas

20

Willoughby

27

Charlecote

21

Squire

20

Malins

20

Hatton

20

23 Hour

18

Dugdale

18

Avon

22

Farries

22

Castle

25

Macgregor

Ground Floor

22

First Floor

20

Victoria

21

Mary

25

Right Sizing Plan - Current

Ambulatory

6

Derm

CCU

9

Amenity

15

6

Surgical

Community

New Block

Medical

Paediatric

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Proposed Timetable of Ward Reconfiguration

July Aug Sept Oct Nov Dec Jan Feb Mar April-June July-Sept Oct-Dec Jan-Mar April-June July-Sept Oct-Dec Jan-March April-June July-Sept Oct-Dec Jan-March April-June July-Sept Oct-Dec Jan-March

110 115 128

255 259 296

310 316 353

365 374 424

1 Creation of a Cardiorespiratory Unit with MHPA facility

2 Orthogeriatric Rehabilitation Ward created

3Avon Ward - Diabetes moves from Farries to Avon (moving from 12 beds to 22 beds)

4 Farries Ward - To be managed by Haematology and Care of the Elderly

5 Dugdale Ward - closes

6Extra capacity / Flex = 23 hour ward / Dugdale From Oct to Nov 2015 if needed (this includes opening of discharge lounge if required)

7 New Ward Block Opens (and Beaumont Ward and Guy Ward close)

8 Oken Ward - Changes its function (becomes ambulatory and doubles in size)

9 Fairfax converts old ambulatory unit to beds (6)

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Winter Contingency - Beaumont Ward (upto 18 beds) / Guy Ward (27 beds) - provides extra accommodation Dec-Mar (longer if needed and this includes opening of discharge lounge if required)

DRAFT DATES - PENDING BUSINESS CASE APPROVAL11 Beaumont - Mid wife led unit Business Case (consider site of GAU) Bus Case Refurbish

12Front Door Resdesign Work - A&E, AEC, MAU (A&E, Guy & Oken) - to include consideration of 5 year future plan for diagnostics - CT, X-ray etc near A&E

Bus Case Refurbish

13Relocation of Dermatology to Jephson Centre (vacated by GUM) - to include med sec move and space vacated at end of Mary ward for rehab space

Move

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Reutilise Dermatology vacant space (End of Squire, End of Mary wards) and support expansion of Medical Measurements and Cardio- respiratory hot clinic/assessment area

Bus case Refurbish

15 Use of Dugdale Area and Discharge Lounge Space - long-term plan (TBC)

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CERU / Stroke - Phase 4 business case (to consider, potential to increase private work, specialised commissioning, Level 2 CCG commissioned beds, Early Supportive Discharge pathway and accommodation at rehab) Long-term - to consider orthogeriatric unit & expansion of outpt clinic space

Bus Case Refurbish Re-locate orthogeriatric if capacity allows

17 Macgregor Ward / PAU / Outpatient facilities (TBC)

SHORT-TERM - DRAFT ARRANGEMENTS

LONG-TERM

A Elective

Current CapacityCurrent Requirement

AvgFuture Requirement Avg

B Emergency (exc Paeds, Babies & Maternity)Demographic growth of 10 beds per yearC Emergency

Total A+B

Right Sizing Plan

Strategic Plan2015/16 2016/17 2017/18 2018/19 2019/20

New ward block creates 12 extra beds = 377 beds

Conversion of beds to ambulatory

reduces beds to 368

Extra capacity between Nov & March ranges

from 18-27 unfunded

Future bed capacity to be confirmed following outcome of business cases for

Midwife led unit and Front End Emergency Work

Long-term bed capacity to be confirmed following outcome of future business cases for example , CERU/Stroke and potentially

Dugdale

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Short-Term Plan – Draft Ward Arrangement Plans Cardiology and Respiratory There is a strong desire to create a Cardiorespiratory and Medical High Priority Area (MHPA) unit in place of CCU where both cardiology and respiratory patients needing more intensive care can be treated. It is at this point worth considering the location of the main respiratory ward and whether it would make sense to reconfigure ward arrangements to create flexibility as the seasonal variation dictates. We know, based on a 93% occupancy there are between 49 and 72 beds needed for respiratory coded patients – whilst not all of these patients will be looked after by the respiratory consultants, it makes sense to create respiratory specialised wards as close to each other as possible. The respiratory team have grown over the last few years and now have a 4.6WTE consultant strong workforce. There are current discussions on-going as to the most suitable location – one suggestion proposed is the creation of a cardiorespiratory unit in Malins, CCU, Squire and Charlecote ward areas. This creates capacity to meet current average demand with developments such as Outpatient parental antimicrobial therapy (OPAT) (pending business case approval) creating further capacity over the coming years. As is currently the case, it is assumed the remaining patients with a respiratory condition, will be looked after by other general medical physicians.

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Each graph compares the last three years occupied bed day requirement for patients with respiratory conditions. The second graph emphasizes the seasonal variation related to pneumonia and acute lower respiratory tract infections. Diabetes, Haematology, Care of the Elderly Currently the diabetes team and the haematology team manage patients on Farries ward. The diabetes team has grown and is now in a position to manage a whole ward and the plan is for the team to manage patients on Avon ward. This creates an opportunity for the Care of the Elderly team to manage half of the beds remaining on Farries ward. This work is underway now and will consolidate the consultant care of patients on Avon ward. Community Beds – Dugdale Ward The current community modelling has been completed and aside from the additional 20, pathway 2, discharge to assess (D2A) beds being created, remains as planned, but in the future, it is clear more pathway 1 and 2 beds will need to be funded by the whole economy – yearly contract discussions with commissioners. A review of the D2A beds will be carried out to ensure they remain fit for purpose and function as expected. In October, the plan is to close Dugdale (community) ward (18 beds) creating an additional 20, D2A beds in the community. The Trust is keen to ensure it does not lose the staff working in Dugdale ward and will be working with the manager and the team to offer suitable alternative employment across the Trust. Just to note, adjacent to Dugdale ward is the discharge lounge. This is currently not in use, but will be available should the need arise this winter. New Ward Block The new ward block business case was developed with the planned assumption that the Trauma and Orthopaedic (T&O) specialty would relocate to this area. The layout of each ward has been developed with this in mind supported by significant time investment from the Trauma and Orthopaedic team. Part of the Right Sizing Plan remit was to reconfirm the planning assumption to move Trauma and Orthopaedic wards to the new ward block when it opens in December. After meeting with staff across the Trust, there appears to be no significant challenge to this planning assumption. Equally there is no convincing arguments to suggest other specialty or specialties would be better suited in this new ward block over and above Trauma and Orthopaedics; it is for this reason and the ward layouts planned, the plan remains unchanged. In summary, the new ward block provides the following: • Ground Floor will become the Trauma ward, providing 22 beds

(Guy ward, 27 beds vacated). • First Floor will become the Orthopaedic Elective ward, providing 20 beds

(Beaumont ward, 18 beds vacated). • Second Floor will become the Amenity ward, providing 15 beds.

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Ground Floor – Trauma (and Orthogeriatric Rehabilitation Ward) We know there is, potentially at any one time, up to 42 trauma inpatients (average 35) and therefore a second area is needed to support the constant flow of patients into and out of the Trauma ward. The Trust is promoting a model of care whereby a trauma orthopaedic ward provides initial care after surgery followed by a transfer a number of hours post operatively to a ‘step down’ rehabilitation facility. An area that can support up to 20-25 beds and provide collocated rehabilitation facilities will be required. It must be noted here that all models have their challenges; the ‘step down’ pathway model being adopted at the Trust may, at times, be difficult to manage with the variation in flow creating a potential impact on trauma patients outlying to other wards and thereby reducing quality and efficiency. Nevertheless, the model is an improvement on the current arrangement. Potential areas identified as being preferable have been identified and provide adequate space around each bed for rehabilitation as well as potentially a small gym facility too (in the long-term). The Trauma and Orthogeriatric and Care of the Elderly teams are currently working on developing a service model to support this work and ensure a daily ‘pull’ of patients from trauma to rehabilitation to home. First Floor – Orthopaedic Elective The ring fenced orthopaedic elective ward currently has 18 beds (Beaumont) and often has spare capacity to accommodate patients from 23 hour ward who are MRSA screened but can’t access a bed. For this new ward to utilise all of its 20 beds it will need to manage all elective orthopaedic work. Currently some of the orthopaedic work, anterior cruciate ligament injuries (ACLs) and shoulder injuries are managed by 23 hour ward, however, the bed number of 20 means the orthopaedic team have sufficient capacity to provide accommodation for all elective orthopaedic work. Even with repatriation of this work the occupied bed days (OBDs) suggest there remains spare capacity to cope with more redirected elective activity. Further work and discussion is on-going to understand what other work could be accommodated through the First Floor, 20 bedded unit; this includes coordinating theatre session planning to more effectively ‘smooth’ elective demand across the week, where possible. Long-Term Plan – Ward Arrangement Development Plans Admission Ward, Ambulatory Unit and Frail Elderly By moving the orthopaedic work to the new block, Guy ward and Beaumont ward become vacant. Beaumont ward is subject to, pending business case approval, a redesign plan to create a Midwife Led Unit (MLU) and extend the Special Care Baby Unit (SCBU). For the purposes of the Right Sizing Plan, Beaumont bed capacity is not factored into the ‘adult’ bed plans for the future. Releasing Guy ward, creates an opportunity to move Fairfax (admission ward) to this area so it is adjacent to A&E. This currently would result in a 3 bed reduction from 30 to 27 beds, but there is potential here to reconfigure Guy and Oken to support the Admissions Unit (Fairfax), the Ambulatory Care Unit and the Frail Elderly Unit to this area / locality. This could potentially create a 42 bedded area to be redesigned as required. The Front Door Redesign work is on-going and will provide a steer for the whole emergency care pathway flow.

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Beaumont Ward Beaumont ward is currently being designed to support a much needed Midwifery-Lead Unit (MLU) and extension of the SCBU. The business case is due to be submitted in October 2015 and will outline the estate footprint required to provide this service based on demographic changes over the next 5 years and potential opportunities to increase market share, particularly from the west side of the county (Redditch and surrounding areas). The Beaumont space may also, in the long-term, re-provide a Gynaecology Assessment Unit (GAU) and bedded area; this will be dependent on the footprint of the MLU and whether the GAU service can have its own separate access. Macgregor Ward – Children The Right Sizing Plan currently focuses on adult inpatient services, however, the plan is aware of the Paediatric Strategy (soon to be renamed the Children and Young People Strategy) and the potential developments being considered – Paediatric Assessment Unit, adolescent inpatient area and expansion of the outpatient clinic facility (including exploring use of community accommodation and Stratford Hospital). This work is on-going, focusing initially on models of care followed up with an estate plan which will then feed in to the Right Sizing Plan in a similar way to the MLU. Dermatology Unit The Dermatology Unit has coped for a number of years in cramped accommodation and an opportunity has arisen for the unit to move into the Jephson building once the Genitourinary Medicine (GUM) department vacate and relocate to other facilities in August 2015. This is the right move for Dermatology; it is largely an outpatient service and does not require its service to be within the main building at Warwick. The new location will create space at the end of Squire ward and Mary ward for potential redevelopment – suggested future developments mooted by staff so far are: • Extension of Medical Measurement Unit (end of Squire ward) • Assessment unit for Cardiorespiratory patients (end of Squire ward) • Rehabilitation facilities Central England Rehabilitation Unit (CERU) Phase 4 and integration with Feldon Ward (Stroke) The business case for Phase 4 of the CERU development is due for submission in September 2015. CERU is a level 1 Acquired Brain Injury unit and has 42 beds with potential to develop the currently vacant ground floor space. Whilst it is not considered in the Right Sizing Plan bed numbers, it does need commenting on as it provides potential capacity when considering this site as a whole and particularly in the long-term. The CERU site also has a stroke rehabilitation ward, Feldon, and is currently working with the Stroke team to integrate services. The overall plan for the CERU / Stroke integration is as follows: • Create shared inpatient ward areas where patients are admitted according to need not

condition; • Joined up nursing and AHP team, also, potentially developing a joined up consultant

working arrangement between neuro-rehabilitation and stroke – work on-going; • Develop a community team to support early supported discharge for all patients and

reduce number of beds;

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• Utilise available vacated bed space to further develop private work, explore opportunities to take on more specialised services work, (if funding approved) and level 2 CCG commissioned ‘step down’ beds;

• Estate – Right Size Plan to include review and improvements to current outpatient and rehabilitation facilities, and

• Long-term clarity on the stroke pathway – yet to be confirmed but likely to demonstrate a reduction in beds on both sites – Victoria Ward and Feldon Ward.

Not part of the CERU / Stroke integration, but to consider opportunities to provide: • Orthogeriatric rehabilitation facility – aligns reasonably well to the major trauma work

CERU currently receives from University Hospitals Coventry and Warwickshire (UHCW). This would create space at the Warwick site if needed in 5 years’ time (long-term plan), and

• End of life / palliative care facility – discussion with CCG regarding current commissioning arrangements needed (long-term plan).

Issues for the Trust – Summary There remain a number of issues, particularly in the short-term, for the Trust. The following list is not exhaustive, but provides an over view of the main issues: • Workforce – the Care of the Elderly team is heavily reliant on locum doctors. This is not

viable long-term and the task and finish group are working on a sustainable plan, including development of a nurse consultant and relooking at GIM.

• Securing elective capacity – as elective capacity increases, there is a risk that some elective 23 hour ward patients will be treated elsewhere, (New Block - first floor and Amenity wards) and create a patient flow issue on 23 hour ward. The reduced elective occupancy on 23 hour ward could potentially be between 8 to 10 beds which would ultimately be filled with medical outliers and stop 23 hour ward functioning as it is supposed to. Discussion currently taking place to understand the options to resolve 23 hour ward patient flow risk such as closing beds, operating 7 days per week and/or using spare bed capacity as winter contingency without impacting on 23 hour elective patients. There is also a junior doctor risk of elective spread across more areas, reducing efficiency such as patients not being discharged on time and theatres not starting on time. The Elective Division will deliver a plan to ensure there is business continuity across all elective areas - this will need to be reviewed once the new ward block is operational.

• Amenity staffing and overall spread of patients across new block wards – Standing Operating Procedures (SOP) to be written before unit opens and to include taking all orthopaedic work and further elective surgical work to ensure 20 bedded unit is utilised well – to be confirmed. Amenity SOP and Bed Management Policy to detail business continuity arrangements during periods of peak demand (winter bed pressure) – ensure Trust reputation is safeguarded.

• Winter bed pressure and unfunded bed capacity (planning for the winter without funding available to staff extra capacity area/s) including the displacement of 12 medical beds created by moving orthogeriatric patients from surgery to medicine.

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− Work on-going to understand the staffing requirements for the dedicated orthogeriatric ward – Nursing, AHP and consultant input (potentially offset by staffing levels from Guy to new ward reducing as beds reduce from 27 to 22).

− Discussions taking place with Dugdale staff to explore opportunities open to them as the ward closes in October (tbc) – staff can move to the community or remain onsite at Warwick but redeployed to vacant posts – also considering staffing requirements for a winter contingency option.

• Ambulatory assessment area is currently too small a footprint – plan in place to

address this in December (see timeline). • Gynaecology Assessment Unit – explore options to move to alternative area. Recommendations and Next Steps The Board of Directors is asked to approve this document as the first iteration of the Right Sizing Plan; further updates will be provided as time progresses and plans develop. It is recommended that the following actions take place alongside the on-going development and refinement of the plan: • The right-sizing and reconfiguration of specialties continues to progress to ensure

service and capacity provision is deliverable in the short and long-term. Initial focus will be on the issues raised in this document and will be included in the Operational Winter Resilience Plan.

• Service delivery teams confirm the risks and achievability of the reconfiguration timetable presented; − Development of business cases as outlined in the timeline: Mid wife led unit Front door redesign – Emergency pathway CERU Phase 4 Other vacated areas created through the New Ward Block opening

− Further service developments identified – on-going and iterative process.

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APPENDICES Appendix 1 – Inpatient Priorities for the Elective Division Increase theatre productivity and capacity to meet predicted demand. Reduce number of elective patients cancelled due to bed pressures – ring fencing beds

through creation of MRSA screened area/s. Trauma and elective orthopaedic wards:

− Co-located together – one team, efficiency (locate all orthopaedic work daycase and inpt including ACL, shoulder, wrists and other (tbc) elective activity if beds available).

− T&O geriatricians to routinely pick up all trauma work; initially only NOF work due to workforce capacity.

− Striving for excellence – the ‘Getting it right first time’ (GIRFT) report published by Professor Briggs (2012), changes to improve pathways of care, patient experience, and outcomes with significant cost savings.

− Recognized as sports injury site. − National Joint Registry – patient improvement and outcomes (recording of Oxford

hip and knee scores, European quality of life – dimension scores and visual analogue).

− Extension of SWAT team to support more activity in community – IV antibiotic work (Ref OPAT business case – in development).

Recruit and retain staff in all areas. Support for prevention and early intervention work by specialty – e.g. focus on reducing

obesity (BMI) in population and support reduction in cancer, orthopaedic demand. Complete next phase of development of CERU. Integrate ABI and stroke services on CERU site.

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Appendix 2 – Inpatient Priorities for the Emergency Division Integrate A&E, Acute Physician and acute frailty service for emergency medical

patients to reduce admission rates, increase emergency ambulatory care, reduce duplication between teams and enhance patient flow.

Implement urgent care clinical workforce strategy. Recruit nurse consultant to develop

MNP capacity and capability to meet the needs of medical wards clinical flow and reduce variation of ward processes.

Develop maternity strategy to implement Midwifery Led Unit and regain / increase

market share. To fully utilise staff, resources and optimise patient flow Cardiology, Respiratory, and

MAU should be co-located / co-joined with an adjacent Medical HPU,CCU and Respiratory HPU. The combination will strengthen cardiorespiratory as an integrated department, with consideration for joint working and sharing of resources and skills. It would support the emergency and acute medical teams by being closely located thus enabling support to be provided more easily. This would address the need for a medical HPU which has been discussed on multiple occasions.

Implement ‘Unipart’ productivity project to meet agreed diagnostic access targets. Recruit and retain staff in all areas.

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Appendix 3 - Soft Intelligence Feedback (General comments) Key risk / weakest link for the Trust: sustainable geriatric workforce to support any bed

reconfiguration / pathway – all areas requesting more geriatric support – orthopaedics, general surgery etc.

New block – an orthopaedic surgical factory with space required elsewhere for ‘next

phase’ of care (emergency trauma) − striving for excellence, ‘Getting it right first time’ − concern over collective responsibility of elderly pt group

Dedicated orthogeriatric area needed (8-10 beds) – ward staff need to be proactive,

involved from day 1 of admission. New block 20 beds elective – acceptance that more patients will need to go through

these beds – ACLs, shoulders etc. Issues: Inc LOS – different ethos, patient flow left on 23 hour – issue.

General acceptance by consultants that T&O should have new block – a few not happy

with amenity idea however (don’t believe it will work, morally wrong etc). 23 hour ward not fit for anything other than short stay – limited use if 23 hr ward moved

– replace with what? Infection control – no issue with how elective split ward areas as long as apply IC

screening process. Infection control – new block – would prefer more access as has more side rooms etc –

trauma therefore helpful as opposed to all elective. Better management of overall demand and capacity:

− Do more elective work in summer and less in winter; − Need more consistent booking system; − Move theatre lists – smooth demand by specialty; − Create work rounds – put daycase on list first so it starts on time & not reliant on

beds. 23 hour ward keen to go to 7 day working to smooth patient flow in and out (effectively

protect beds). Issue currently, no extra capacity ward available – 23 hour still open at weekends (May 2015).

Idea of moving acute medicine ward nearer to A&E makes sense. Concern of where gynaecology assessment would go – not suitable back to Beaumont.

As it is at the moment. Oken ward – mix of frail elderly and gynaecology does not work.

Recommend original ward footprints are re-established. Medical wards – junior staff appear less able to discharge patients without

consultant/registrar review.

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Ward round by physicians – slow to see/review outliers. Some wards much more proactive – problem solving first, working patients up ready for

consultant WR rather than waiting to hand work onto consultant – recognise this is vital if orthogeriatric area created – suggested Charlecote.

Gastroenterology ward – happy where they are, it works, they have good view of 3-4

key beds – essential. Frustration at inconsistent bed management policy. Respiratory - Potential to move to Squire and Charlecote - create space for

assessment area where Dermatology is and Critical Care Unit (CCU) become cardio-respiratory area – (only 1 consultant view).

Concern, Squire not fit for purpose. Lack of consistent bed management process - No value added for pts going via A&E,

Fairfax. MNP add value – need them at weekends, need to release them from admin work.

Role of nurse consultant – in orthogeriatrics?