UK: Split Sites: Divide And Conquer?

Last Updated: 8 October 2019
Article by Anne Crofts and Alistair Robertson

More trusts are turning to the 'split site' model to redesign how and where they deliver services. Such re-engineering requires skilled leadership, and staff and public engagement, but is this a panacea?

In 2016, Gloucestershire Hospitals NHS Foundation Trust was, according to Chief Executive Officer Deborah Lee, facing a number of pressures: "Not only were we in financial special measures, there were rising waiting times and increasing numbers of operations being cancelled at short notice in a number of services including orthopaedics, £6 million of NHS work was being done in the private sector, productivity wasn't what it could have been and we were not serving staff or patients well."

Taking a cue from the NHS good practice Getting It Right First Time (GIRFT) programme lead, Professor Tim Briggs, along with Lee's previous experience of seeing the success of splitting trauma and orthopaedics in North Bristol NHS Trust, the Trust worked at rapid pace to separate orthopaedic services onto two sites: one 'hot' site predominantly for trauma, and a 'cold' for planned surgery. Outpatients and day surgery remained on both sites, which was considered important for maintaining local access to services and supporting training.

By May 2018, after six months of split site working, the Trust was achieving its four-hour A&E trajectory for the first time since 2010, pre- and post-pilot mortality from a fractured hip has reduced by more than 25%, on the day cancelled operations have reduced from a weekly average of 9.75 to 0.5, waits for trauma have improved and routine waiting times are falling. Bucking the national trend, the Trust saw a 14% increase in joint surgeries in Winter 2018 over 2016, despite using fewer beds and theatres.

At least six other trusts, including organisations in Cornwall, Lincoln and Kent, who want to go down the split site route, are now 'buddied' with Gloucester, which is an "official exemplar site", says Lee.

LTP revival

Splitting services is not new, indeed other countries adopted the idea of elective only units for joint replacement and other routine procedures, but it has been refreshed in the NHS Long Term Plan. The Plan indicates that providing planned services from a cold site guards against the capacity being taken up by emergency admissions, reducing the risk of last-minute cancellations.

Meanwhile, the Plan says that managing complex, urgent care on a separate hot site allows "improved trauma assessment and better access to specialist care, so that patients have access to the right expertise at the right time".

NHS England says it will continue to back hospitals that wish to pursue this model, but in those locations where a complete site shift to cold elective services is not feasible, it may also introduce a new option of 'A&E locals', the details of which are yet to be unveiled.

Clinical buy-in

Lee says the fact that the Trust operated from two large sites, Gloucestershire Royal Hospital and Cheltenham General Hospital, led to wasteful duplication: "We were trying to do everything on the two sites and that caused problems. By the time we found ourselves in financial special measures, we had seen what North Bristol had done, so split sites stacked up." 

Lee says the Trust had been "dancing around" the idea of splitting services for a decade, "but a lot of clinical voices meant we never made any progress".

It was the combination of pressures that persuaded the Trust to consult staff. "The first step was to get clinical buy-in – we needed the commitment to do it." 

Part of the difficulty was the simple logistics of getting the Trust's 27 orthopaedic surgeons together. Once they were all gathered, Lee says the meetings threw up some really challenging conversations:

"There were lots of people doing private practice in the room, lots of older established consultants who were very resistant to the model and on the other hand some younger people who really thought it was the way to go.

"It was a real personal leadership piece with Tim (Briggs) and myself running big events in hotels in Gloucestershire explaining to people why we should be doing this."

Duplication

Lee stresses that there were no significant costs involved, rather "it was about re-arranging what we had".

The only expenses went on creating an MRSA-free environment on one ward, a fair bit of time for project management costs and, more significantly, re-writing job plans for 27 consultants and their juniors.

"That was probably the most onerous task. There were lots of concerns about teaching and trainees, so it took time making sure that the operating model of the service didn't undermine the ability to deliver teaching as well as care."

Over 18 months later, Lee says the move has completely changed the way people work: "One week you are part of the hot team at Gloucester doing theatres, A&E and wards and the next you're in Cheltenham doing four arthroplasties on a list.

"What's fascinating is that the vast majority of the team think it's great. We had 27 applicants for our orthopaedic vacancy because it's gaining repute as a great place to work. We have 70% of our surgeons doing four arthroplasties per list, who were doing 2.5 before the change. We were operating on New Year's Day when most trusts were sunk by winter pressures."

One of the criticisms of the model is that it does require a duplication of some emergency services on the elective site in case things go wrong.

"Both sites have a critical care unit so if a patient has a pulmonary embolism that is still treated there, not down the road at another hospital," argues Lee. It's not without its challenges but has been "by-and-large a success".

DAC Beachcroft Partner, Alistair Robertson, who specialises in NHS service reconfiguration says early and well-publicised engagement with the public and other stakeholders, including the local authority, is vital:

"It is especially important where removing some services from one site might be perceived as a downgrade or an excuse for cuts. And it's not just the public, but clinical commissioners who would want reassurances that a cold site would have emergency cover should something go wrong. 

"Reorganisations of this nature are ripe for challenge, and lack of (adequate) consultation is almost always first on the list."

He says it is vital that in preparing for any restructuring of this nature that trusts ensure that the rationale meets the Government's four tests set out in the NHS Mandate: strong public and patient engagement; consistency with current and prospective need for patient choice; clear, clinical evidence base; and support for proposals from commissioners.

Robertson also notes the fifth test subsequently added by NHS England Chief Executive Simon Stevens: "Where there are proposals that cut beds, trusts must demonstrate that there is additional added capacity in the community to match the closures."

No single solution

Nigel Edwards, Chief Executive at the Nuffield Trust, says there are a variety of different models of split site ideas around the world, including the South West London Elective Orthopaedic Centre:

"These seem to work very well with a standard processing system that reviews patients very quickly and provides low infection rates, and does not get affected by loss of capacity due to winter pressure.

"In places like Gloucester, the theory is that you will still have to have some elective work at the hot site, especially for complex procedures. With a big bowel resection on a cold site, for example, you might still need a critical care unit if complications occur."

Edwards' main concern is whether the expense of duplicating some emergency services is outweighed by consistent better outcomes: "I would like to see whether there is a higher or lower perioperative risk after a split."

The Royal College of Surgeons supports reconfiguration of surgical services so long as they are underpinned by strong clinical evidence, and accompanied by meaningful public and stakeholder consultation.

College President, Professor Derek Alderson, says that split sites can enable a greater volume of elective surgery to take place, helping reduce waiting times: "The GIRFT programme has recommended that commissioners and providers develop elective orthopaedic services on cold sites, or within existing hospitals that have a robust 'ring-fenced policy' that can function separately from the main hospital.

"Given the record elective waiting list reported in June 2019 (4.3 million patients) – we need to look urgently at how to increase the volume of elective activity across the system. This will take both political will and meaningful engagement with clinicians, patients and the public. It cannot be forced upon local areas, but it is essential to addressing the problem of so many people waiting in pain, often with their condition deteriorating."

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
 
In association with
Related Topics
 
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Mondaq Free Registration
Gain access to Mondaq global archive of over 375,000 articles covering 200 countries with a personalised News Alert and automatic login on this device.
Mondaq News Alert (some suggested topics and region)
Select Topics
Registration (please scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions