Diagnostic and Treatment Centres: the future of healthcare?

Tuesday 13th May 2003 at The Commonwealth Club, Northumberland Street, London

Future Healthcare Network (FHN) held a joint seminar with Architects for Health which explored the Diagnostic and Treatment Centre (DTC) models being developed in public and private sectors, those emerging from whole system planning and the potential for this initiative to deliver modern services appropriate to local needs.

Presentations were given by representatives from the Cabinet Office, Department of Health (DoH) Independent Sector DTC Programme and trusts developing DTCs with a discussion lead by panel of experts. Issues that emerged included the potential of IT to support and enable whole system planning, the potential to develop planning in primary, acute and social care in an integrated way, and the potential to increase capacity to meet short term targets.

AfH member Roger Walters of Bickerdike Allen Partners comments on the event:

Public debate has recently focused upon Foundation Hospitals but delegates at the first joint AfM/FHN Meeting saw the radical side of NHS modernisation. The architects in the audience were not that surprised to find design again well down the agenda. However, many were surprised by the radical nature of the dtc component in the NHS Plan. This is a redesign of the existing service as well as “growing capacity”.

DTCs are for elective surgery and may well come in a wide variety of shapes and sizes. Mostly, they will be for hip, knee and eye procedures but a wide range of different specialities will be covered; some are acute services orientated, others community or primary care focused. Some will be firmly within the NHS; others will be additional new capacity provided by the private sector. Some will be delivered and operated by UK providers but more are likely to be delivered by new foreign operators in order to address the medical and nursing staffing issues raised. Indeed, a feature of the meeting was the range of interesting questions raised by this modernisation.

This may well be a start of the break up of the NHS monopoly on acute provision within the NHS. Some competition is being introduced both to increase capacity and improve choice in a more consumer responsive service still free at the point of delivery. Improved access and reduced waiting times, lengths of stay and costs/procedure are also key objectives. The label ‘surgery factory’ does appear to be quite accurate. The justification for the role of the private sector here is to ensure that the new capacity is indeed additional capacity. It is design, build, finance and operate in every sense. It is about ‘getting things done’ with improved patient choice in a modernised NHS and ideally before the next election.

The presentation raised several interesting questions:

• to what extent is existing public and especially existing private capacity fully utilised
• what happens to many existing business plans when these new facilities come on stream
• to what extent do these new facilities release bed capacity in existing hospitals
• can these public and private dtcs really be kept so separate that there is no loss of NHS staff
• does this change surgical training and career opportunities within the NHS
• are there cross subsidies (which are at present hidden) which will make remaining. treatment more costly
• is a short term contract for providers sufficient to allow the development of quality facilities
• how is residual value handled in this context of 5 year concessions
• is standardisation really appropriate given the even shorter design time
• is telemedicine not already overtaking much of this programme already
• what are the new models of organisation: stay and day
• is this going to be a satisfactory patient experience
• is design innovation desired and how does this fit within the business and marketing strategy

This was a fascinating session. More questions than answers but there was no mistaking the clear intent. This programme would clearly benefit from wider public scrutiny given the issues raised. Some schemes may follow the pioneering example of Avanti’s ACAD scheme at Central Middlesex Hospital but it seems ironic that such a promising start appears to being overlooked in the headlong rush for instant delivery.

Copyright is retained by individual speakers and AfH is grateful for permission to include the material on this site.

Roger Walters

SUMMARY

Diagnostic and treatment centres are a vital development in the strategy to address capacity issues in the NHS. Designed to carry out planned surgery and treatments, there are now emerging models for acute and primary, and public and private sectors.

What are they? And how will they optimise potential to deliver modern services appropriate to local needs?

The Future Healthcare Network held a joint event with Architects for Health in May 2003 to explore these issues with presentations from policy and practice.

Summary of the key issues from the event:

• Policy: DTCs are seen as a key component in health services reform, particularly in relation to patient choice.
• The independent sector: can offer a fast, innovative alternative method of procurement. By bringing clinical expertise from abroad, it has the potential to add workforce capacity. But it may meet with resistance from clinical professionals particularly since it is such a ‘top-down’ initiative.
• Newham Acute NHS Trust: the DTC is seen as a building block in redeveloping the whole site. It is increasing physical capacity in a stand alone facility that will enable and support other changes. Defined patient pathways are being developed and there are links with other stakeholders and initiatives such as LIFT. The model of separating elective and emergency care is one that is being developed in other acute settings.
• The Lymington Community Hospital: the PCT is developing a model that demonstrates the potential for DTCs to develop community hospitals in primary care settings.
• Primary care: this initiative demonstrated the potential for joined up IT and workforce between primary and acute trust, introducing the idea of virtual DTCs – or DT Services, as they were redefined!

Panel responses highlighted the following views:

• The Modernisation Agency regard the DTC programme as a vehicle for modernising services
• The entrepreneur described the potential for it as a consumer driven model
• The architect drew attention to insufficient planning time and skills amongst clients
• The trust remarked on the poor evaluation of options and lack of strategic integrated planning

AGENDA 1.30pm to 6.00pm

Coffee and Arrival (15 minutes)

Introduction and Welcome (5 minutes)

Susan Francis, FHN and AfH

What is a DTC? What are the policy issues? and the models? (20 minutes)

Pippa Bagnall – Principal Advisor (Health), Prime Minister’s Office for Public Services Reform

The Prime Minister regards DTCs as a high profile development for the NHS. This was underlined by the fact that he had hosted a breakfast to discuss the subject for public and private sector stakeholders.

There are three strands to be considered in relation to the reform of health and social care:

• quality of care
• people who provide the care
• where the care is provided.

It is important to get the environment right. This can be achieved through stakeholder partnerships.

Partnership is seen to be the way forward. There are five types of current provision/partnership:

1. Public sector default (the public sector provides all services)
2. Private sector rescue (when the public sector is deemed to be failing in some way and a private provider is ‘parachuted in’ to sort things out)
3. Level playing field (a balanced approach involving public and private sector)
4. Public sector rescue (the private sector provides all services unless it fails and the public sector steps in)
5. Private sector default (the private sector provides all services).

The NHS plan puts a strong emphasis on flexibility. That is a driving force behind the DTC agenda.

It is important to see DTCs not as just a way to solve waiting list problems: they are about providing better care and more efficient care, using the workforce more effectively and efficiently and responding to what the consumer wants – rapid treatment, convenient care from the patient’s point of view.

Trusts need to be creative in their thinking about how to develop DTCs. Primary, acute and independent models are all evolving.

Points from the discussion

• There is an assumption that by improving efficiency you can bridge the gap between healthcare need and resources, but as needs are met, more needs appear.
• The DTC programme is primarily about increasing capacity and decreasing waiting.
• Patient input should be at the centre of DTCs.
• There is a business case for good design, particularly in terms of safety, environment and sustainability.
• Is there/should there be a role for alternative medicine in DTCs?
• Although there is often a resistance to change, with DTCs people seem to be more welcoming of change. This may be a reason why the initiative will succeed.
• It is easier to define what a DTC isn’t than what it is. It is about ways of working, multi-skilling, integration, buildings and patient focus.
• There is need to share best practice, involve designers as early as possible, thing about where DTCs will be located, work with planners, work with patients and users.
• Need to increase/improve use of technology

Case Study: Independent sector (25 minutes)

Ken Anderson, Head of the Implementation Team, Independent Sector DTC programme, DoH

Independent sector DTCs are important because they can help the NHS produce the increases in capacity needed to deliver service targets such as reductions in waiting times. They will also give the NHS some ‘breathing space’ which will help it to change. Lead times for conventional NHS projects mean traditional solutions to capacity problems cannot deliver.

Ken Anderson’s team is working with private sector providers to find the best ways of getting them involved. Priority areas of need are identified, but the team is also mindful of the need for economies of scale. Anderson is clear that the people who staff the independent sector DTCs should be ‘additional’ people, not staff taken away from existing health services. The DTCs will all be ‘branded’ as NHS facilities.

The core objectives of the DTC programme are to:

• improve access to elective care
• streamline the way the NHS provides diagnostic and elective care
• generate value for money gains by stimulating new models of service delivery.

DTCs should focus on streamlined day surgery.

DTCs (or ambulatory surgery centres as they are known in the US) have become popular in the US. Patients find them convenient, partly because they can schedule their treatment. It has also been found that post operative infection rates are lower. The first centre in the US opened in 1970; today more than seven million surgical procedures are performed each year in 3,300 centres. Types of surgery include ophthalmology, gastroenterology, gynaecology, orthopaedics, ENT and urology.

For the NHS, DTCs offer an opportunity to adopt best practice and increase short term capacity through new ways of working. There is not a prescribed model for a DTC; for example it could be on NHS property or in a shopping centre. There are no set ideas on structure as long as the DTC is fit for purpose. Trusts may even want to consider leasing a facility and learning from how this works before building a tailor-made DTC. In the US, mobile DTCs are used in some areas.

It is important to ensure that DTCs have shorter set up times than the NHS has been used to. The starting point should be the patient pathway, with the bricks and mortar regarded as the fabric that holds the pathway.

The case mix will vary from DTC to DTC, but each will be expected to support its case mix, for example by having imaging services that support its work.

DTCs represent a new way of engaging the independent sector, with long term contracts for services, a highly informed procurement process and the opportunity to learn from global best practice in procurement and supply chain management as well as in clinical terms.

Points from the discussion

• DTCs are (partly) being introduced to target waiting lists as they exist now. What happens when lists have been controlled?
• Should we look at separating specialities even further? For example, separating the two specialisms within orthopaedics to maximise productivity?
• Issue of politically driven programmes to set up DTCs – this may mean moving at a pace that is too quick, building in haste with construction starting before the design is finalised.
• Is a 30-year life too long for DTCs? Should we just build for 5 years? Contracts usually run for 5 years and then are subject to market testing again. It is best to think of the building as a facility to be used as wanted.
• Should buildings be tailor made, or could a warehouse, for example, be leased or spare office space used? Architect view expressed that flexibility is a good idea but limited concept in practice.
• There must be clear protocols with the independent sector: if it gets things wrong it must put them right and pay.

Case study: Newham Healthcare NHS Trust (25 minutes)

Monica McSharry, Director of Service and Organisational Development, Newham Healthcare NHS Trust

Newham is looking to centralise all acute services on one site. The area already has quite advanced partnership working and has LIFT and New Deal for Communities projects underway.

By centralising acute services trust is looking for flexibility and a critical mass which could help it find a long term solution to capacity problems and enable patients to receive more care locally. At the same time, it is intended to make more services community based particularly through the LIFT project which is building primary care one-stop facilities.

The main site will include a DTC. Its aim is to deliver high quality, cost effective scheduled diagnostic and/or treatment services that optimise service efficiency, clinical outcomes and maximise patient satisfaction. Its defining characteristics will be that:

• it embodies best and most forward thinking practice in the design and delivery of the services it provides
• it delivers a high volume of activity in a pre-defined range of routine treatments and/or diagnostics
• it delivers scheduled care that is not affected by demand for, or provision of, unscheduled care
• services are streamlined using defined patient pathways
• services are planned and booked, with an emphasis on patient choice and convenience
• it provides a high quality patient experience and creates a positive environment that enhances working the working lives of staff.

So far, orthopaedic pathways have been established, and others are being looked at with patient choice groups. The trust is also consulting users, that is people who may accompany patients or visit them at the DTC.

Procurement methodology has led to the project moving ahead very quickly – overtaking the main PFI project.

Diagnostic capacity will be provided within the DTC, but the trust is not assuming that all the pre-operative assessment will happen within the DTC. There is an ambulatory care setting on the site that will deal with this.

Facilities and services need to be flexible, able to expand and contract. It will be supported by good IT, which will link up with primary care so in the future GPs will be able to book diagnosis or treatment for patients direct to pre-assessment process on straight on to theatre lists.

The trust is investing heavily in support staff to make sure the social care element of travelling through the DTC has got as much priority as the clinical component.

The trust is also making sure the DTC reflects the need of the local community. For example community groups have looked at the designs. One suggestion for them is to have more prayer rooms as the area has a large Muslim community – users and clinicians. Local people have also said they want to use the centre as an educational facility, coming in to pick up education about healthcare.

It needs the ability to engage with a wide range of providers and the trust has looked at having visiting teams staff the unit, having national establishments, having clinicians from neighbouring authorities coming in to do operating lists, and also looking at different roles and different practitioners that can work in the facility.

The DTC will be a stand alone facility with 57 beds and eight day care trolleys within three ward facilities. There will be two operating theatres, a minor procedure theatre and two treatment rooms. The eight consulting rooms will have direct access to diagnostic facilities. Different parts of the DTC will work different hours. There will also be a pharmacy, health shop providing health information, and a café. It will cost around £14.5 million, but this figure is inflated because the site needs to be cleared of contaminated land.

Clinically, it will cover urology, gynaecology, orthopaedic and general surgery. The trust estimates that these areas account for 96 per cent of its surgical activity. Around 80 per cent of this activity is covered by about 20 procedures.

Treatment will be quicker. For example patients who have hip or knee replacements are likely to stay at the DTC for four to five days, whereas the average stay now is around 14 days.

Consideration has also been given to ways to overcome problems of recruitment in some areas; for example, whether imaging services could be provided remotely by using IT.

The anticipated benefits are:

• For the patient: separation of elected and emergency care; more personal environment; individual needs and concerns addressed; better access; more convenient.
• For the clinician: more able to practice at ‘best practice’ levels; less disruption to elective scheduled work; greater ability to increase throughput; more management input; more efficient, patient focused environment; opportunities for new ways of working.
• For the trust: improve resources for emergency flows; positive impact on waiting times and cost control; increased patient and staff satisfaction; aids retention and recruitment of skilled staff.

The trust has identified a range of issues that relate to the DTC that it needs to address. For example, it will need to manage the introduction of GP specialists and develop their role in community settings; it has more work to do to make sure the IT infrastructure is in place; the roles of hospital staff within the new set up need to be defined; the impact of design on function (and vice versa) needs to be thought through so that flexibility is maintained; the affect on the training of staff needs to be considered as the DTC will take things away from the hospital as a learning environment.

Points from the discussion

• Lots of organisations are studying care pathways. This information should be widely shared.
• If you are taking elective care out and protecting it from emergencies influencing and detracting and stopping you admit patients. If DTC works as it should work, what do you do with the acute trust? The acute trust should learn from the DTC so everything gets modernised.

Case study: Lymington Community Hospital (25 minutes)

Sue Howson, PFI Project Director, New Forest PCT

The New Forest PCT operates six community hospitals. It is currently planning a new hospital to replace the existing Lymington hospital, and this new hospital fits the characteristics of a DTC.

The PCT believes it is well placed to run a DTC as it has the ability to see the whole of the healthcare system and is able to match rehabilitation service to diagnostic and treatment procedures. The facility has been planned with partners – particularly acute providers and social services.

The PCT also thought that opting for a DTC would enable it to build under PFI (earlier applications to build a new ‘PFI’ hospital had been unsuccessfull.

The DTC was seen as a chance to ‘start again’, in terms of the services provided and the type of building they would be provided from. Early thinking took in systems and process redesign, as well as new roles for staff. The DTC was to be based around people working as teams rather than individual practitioners. There will be a multi-professional triage team that deals mainly with orthopaedics.

The brief for the building designers, therefore, calls for a structure that can keep people together as teams, with buildings built around the patients and patient pathways. The brief also says that the buildings should have maximum flexibility to allow for change, and advanced use of IT such as EPR and telemedicine.

A series of workshops were held with stakeholders to help in planning the building. These suggested that space should be regarded as ‘a resource not a territory’. There was also a need for good public space, private areas where people could talk to clinical staff or be alone if they need to, social space such as a café and education facilities. There should be ‘natural overflows’ from waiting areas.

It was seen as important that this would not just be a place where people come to get treated, but rather it should be seen as a community facility.

The concept of ‘day and stay’ emerged from thinking about what has been called the ‘pace’ of the building: medical day case needs a slower process than day surgery. The idea is to keep the ‘day’ part away from the ‘stay’ part in the design.

A great deal of attention has also been paid to services and ‘adjacencies’, that is, which services need to be near which. This meant looking carefully at how services within the DTC would relate to each other.

Benefits of the DTC are seen to be that

• it keeps the NHS local
• it identifies and responds to new care pathways
• it integrates primary, community and social care
• it promotes workforce modernisation
• it reduces demand on acute facilities.

Case study: Chorleywood Health Centre (25 minutes)

Dr Russell Wynn Jones GP

Some of the answers that DTCs are looking to provide already exist in general practice.

General practice trying to ‘bolt’ a number of things together to make a difference: making access to NHS service better and more pleasant, making pathways more effective, understanding more disease profiling and providing healthcare at or close to home – i.e. without patients having to go to hospital so often.

GPs at the centre started to change the way they worked to provide a broader set of services to undermine the idea that you always have to go to hospital with a question. If the patient did have to go to hospital they should go with a diagnosis that was as accurate as possible.

This included looking at areas where services could be provided by others. For example, six graduate nurses now run morning surgeries and diagnose and their diagnoses are recognised as being ‘as good as’ that of the GPs. Liked by patients. Another example sees a nurse and a physiotherapist training to use imaging systems. Changing the way GPs work should allow them more time to develop specialist skills.

Attention has been paid to matching need to services, reducing access time, profiling patient populations, developing a patient register and an electronic patient record system.

Usually the patient has to move around a great deal and wait on different parts of the health service to respond. The practice has developed the use of IT to provide ‘virtual consultations’, where the patient and GP are connected directly to, for example, a CHD consultant via video-conferencing/web-based technology. This can save the patient the procedure and time of booking an appointment with a consultant and can lead to better diagnosis as the doctor and consultant can confer and ask the patient questions in ‘real time’.

Another pioneering technique for consultations has been to have more people present with the GP and the patient, for example a nurse and another doctor. Again, this has been found to improve the quality and accuracy of diagnoses.

The practice has looked at how it can provide some of its own imaging services and use technology to provide imaging services remotely. For example, video technology was able to save an elderly lady a visit to a clinic when her symptoms were shown ‘live’ on video to a consultant.

The surgery has an 86 per cent accuracy rate for diagnosing.

Surgery looked at its patients in the local acute hospital. Found that over half need not have come to hospital, about 30 per cent may not have needed to be there at all. Worked out that most could be stabilised in 72 hours. The practice thought it could ‘do something about’ acute illness. As a result it is also using technology to provide better home care. For example, having recognised that many terminally ill patients do not achieve their wish to die at home, a ‘virtual’ bedside monitoring system is being developed.

There is no reason why General Practice cannot be regarded as a DTC. The issue is services not buildings although there needs to be clarity over responsibility and ownership.

Providing for the flow of information is key.

General Practice can provide a range of ‘DTS services’, particularly the diagnostic element. This can include imaging services such as ultrasound and fundoscopy as well as duplex scanning, gastroscopy, sigmoidoscopy, echocardiography and stress testing.

Ingredients for successful DTSs are seen to be:

• active involvement of primary care
• specialist medical skills
• multi-skilled technicians
• multi-skilled nurses
• shared electronic records
• broadband for images
• established systems and links between practices and DTSs and their secondary and tertiary providers.

Tea

Panel Discussion (30 minutes)

Chris Higdon, Programme Manager, DTC Programme, Modernisation Agency

Chris covers the 46 announced DTC sites nationally.

Role of the Modernisation Agency programme is to link with all the DTC sites, work with the Department of Health and strategic health authorities and to make sure that the capacity gap that has been identified and can be filled by the DTCs actually transpires (and there can be difficulties measuring this).

The programme’s role is to help the DTC sites maximise what they can produce with the new facilities. Some of this will be looking at workforce issues – for example difficulties with diagnostics could become a ‘hidden waiting list’.

The team is working on workforce redesign, patient flows, integrated care pathways and a range of other issues.

See a lot of workforce redesign going on, and there are huge skills that need to be tapped into and nurtured.

Dr Michael Sinclair

Private investment driven by consumerisation of healthcare and by the fact that 40 per cent of premature deaths can be avoided by changes in behaviour (only a 10 per cent reduction can be achieved by more medical care). This points in the direction of business that should be the focus of attention in DTCs.

How can the businesses that he is involved with be involved in DTC programme? For example:

• Facilitating communications between patients and physicians – mostly on the web
• Nurse staffing – dealing with pressures on recruitment and retention
• Universal translation system that allows organisations to communicate without having to change hardware or software
• Interactive technology – put the patient first: eg NHS pilot involved a group consultation (20 hip replacement patients) having consultation from their homes, using keyboards to put their questions to a medical team. Result was that patients had more than an hour with the medical team. Patients learned from each other’s questions.

Sue Wainwright, Partner, Tangram Architects and Designers

Involved with two DTCs: one (Epsom) is orthopaedic surgery based, the other (Harlow) for general surgery. Both have pre-admission education units and same-day admission areas.

The Epsom DTC had a mentor – the hospital for special surgery in New York. New York hospital specialises in knee and hip surgery.

Both of the projects started with politically driven programmes (‘from now until the next election’). Caused difficulties because the programmes were no longer than the normal construction programme for those buildings. Clients with little operational policy, no brief and no design, yet needing to open in 30 months. There is a need to find a way to maximise the most of that total time to enable them to develop their operational policy. The design process had to be moved on with a group of people who were still thinking about how the project would work.

This leads to a danger of building the wrong thing in haste. And construction has to start before design is finished, something we always used to try and avoid.

Architects and designers find themselves cross-fertilising clinical ideas between projects.

Shortage of time leads people to suggest prefabrication, but there are long lead-in times and conventional design can give you more time.

Dennis O’Keefe, Project director of PFI scheme in Bristol

Working closely with an independent provider hip and knee factory.

Procurement programme for new centre is very quick – from May to September.

Issues of concern include pre-operative assessments, what happens if things go wrong, clinical negligence.

Using Design to change services
Chris Higdon, National Programme Manager, DTC Programme, NHS Modernisation Agency

An investment and entrepreneurial response
Dr Michael Sinclair, Chairman, Yoomedia

Implications for planning and design of buildings
Chris Shaw, Architect, MAAP

Making it happen: Capacity and timeframe
Alison Evans, Assistant Director – Modernisation lead Greater Peterborough PCTs

Discussion (45 minutes)

Close with thanks (15 minutes)
Paul Mercer, Secretary, Architects for Health

Wine and canapés