Relocation of Colorectal and Hepatobiliary Services: Engagement Report

Background

The national picture indicates that waiting lists have grown following the Covid-19 pandemic. A challenging winter with increased urgent care demand and Infection Control Procedures requiring segregation of Covid positive patients has meant that elective activity has not yet increased to the levels required to treat current backlogs and manage current demand.

Nottingham University Hospitals (NUH) have received a capital investment of £15 million to provide an additional 20 bedded ward on the City Hospital site. The Trust also put together proposals for a modular building comprising three theatres and a 10 bedded Enhanced Perioperative Care Unit (EPOC) which would allow for a phased refurbishment of existing theatres while also easing pressure on critical care. The two facilities would provide additional capacity to enable elective (planned) colorectal and simple case hepatobiliary surgery to move to the City Hospital from the Queen’s Medical Centre (QMC), thereby helping to reduce elective waiting lists as well as increasing the number of beds available for emergency patients at the QMC. Outpatient appointments, diagnostics and pre-operative assessment would remain at the QMC and the Treatment Centre, with no change to service delivery.

In July 2022 Nottingham and Nottinghamshire ICB sought support for these proposals from the Nottingham and Nottinghamshire Health Scrutiny Committees (HSC). Both Committees endorsed the paper, advising that the ICB should conduct a more targeted approach to patient engagement in respect of the relocation of elective colorectal and hepatobiliary services whilst ensuring capturing the impact on patients.

Methods

An online survey was developed (with paper copies also made available) to offer patients the opportunity to share their views.  The survey was also received by patient and public representatives to ensure that the information was clear and public facing.  The engagement work commenced on the 2 November 2022, with active promotion in outpatient clinics, supported by volunteers.  A total of 22 surveys were completed.  Concerted efforts were made to obtain feedback from patients via various different ways and means including a survey, posters in outpatient clinics with access to information about the engagement activity, invitations to any groups meeting and also the help and assistance of a NUH Volunteer to complete surveys with patients in the clinical setting. 

The table below outlines an example of the number of people who were accessing the services prior to Covid .  The numbers are based on an annual total.

Key findings

• 70% found the quality of care during admission to the colorectal and hepatobiliary (HPB) service to be positive (excellent or good), 20% rated it as poor or very poor and 10% felt neither good nor bad.
• 36% of respondents were in favour of the proposals for their surgery to be carried out at City Hospital and for the outpatient and pre-operative clinics to remain at QMC. 32% of respondents stated they would prefer to be seen at QMC with 32% neither stating their preference to either site.
• By a slight majority, the City Hospital was rated as the easiest hospital to access for patients, with 58% rating their access as excellent or good, compared to 44% rating access to QMC as excellent or good. 
• 55% respondents rated the environment where they were treated and received care as excellent or good, 15% found the environment to be poor and 30% of respondents opted for neither good nor poor.
• Comments from respondents referenced the limited car parking facilities at City Hospital, which they felt would be problematic.  Suggestions were made from respondents about the possibility of extending the car parking areas or improving public transport links to the hospital.   

Next steps

The findings from the engagement work will be presented to the Health Scrutiny Committees in Nottingham and Nottinghamshire for further consideration and subsequent actions. This report will be available on our website for communities and networks.

Conclusion 1:

Access to both hospitals is equally challenging, particularly in relation to car parking which on both sites is limited and expensive.  Public transport is more readily available for the Queens Medical Centre, but the majority of patients were nonetheless still in support of traveling to the City Hospital if the service were relocated there.

Recommendation 1: Adequate car parking spaces to be considered at City Hospital to accommodate the increased number of patients attending surgery together with a review of parking fees and potential improvements to public transport routes for those who do not have access to their own vehicles. 

Conclusion 2:

There may be a some access and travel impacts for some patients who will need to access the services at City Hospital from surrounding areas of Nottingham.

Recommendation 2: Consideration should be given to understand the impact  for those patients and carers across Nottingham and Nottinghamshire when accessing services on one site and work in partnership with Local Authorities to provide information on suitable bus routes to the sites together with travel times.

Conclusion 3:

Respondents felt that information provided before the surgery could be improved.  Information about aftercare post surgery was also highlighted as a concern. 

Recommendation 3:  To review patient communications and patient-facing information provided both before and after the surgery to ensure clear and consistent information is given.

National context

The national picture indicates that waiting lists have grown following the Covid-19 pandemic. A challenging winter with increased urgent care demand and Infection Control Procedures requiring segregation of Covid positive patients has meant that elective activity has not yet increased to the levels required to treat current backlogs and manage current demand.

Systems are required to develop ‘Elective Recovery’ plans that deliver activity at 110% of pre-Covid levels in 2022/23 increasing to 130% by 2024/25. National planning guidance has a number of key priorities for transformation to inform these plans including the requirement to fully utilise the recommendations of the Getting It Right First Time (GIRFT) programme to increase elective capacity making best use of resources. This includes the creation of ring-fenced elective capacity in ‘cold sites’ otherwise known as ‘Elective Hubs’ that separate urgent and elective pathways and patients. A review by the national GIRFT team has recently been undertaken and our clinical leads have committed to developing plans to:

• Ring-fence elective capacity on a site that is away from the main A&E
• Maximise productivity through better use of theatre and ward areas
• Focus on six High Volume / Low Complexity procedures in line with national recommendations. This includes general surgery and therefore colorectal and HPB.

Local context

Regionally, winter pressures continue within the NHS with further delays in routine elective care as clinically urgent and cancer patients have been necessarily prioritised for treatment. The impact of Covid and Flu has resulted in continuing emergency demand, lack of interim bed capacity to support discharge and staff absence to a level that is outside of seasonal norms.

Currently elective bed and theatre capacity is too often impacted by emergency demand meaning patients have their appointments cancelled at short notice. To reduce the existing backlog of patients waiting for treatment, we also need to maximise and make better use of our elective capacity this year.  Waiting lists for elective care have increased across the Integrated Care System (ICS) and in particular the number of patients waiting longer than 104 weeks at NUH. Routine elective care is vulnerable to cancellation when there are increased emergency pressures and discharge delays.

Capital investment of £15m is available 2022/2023 to provide:

• Additional 20 bedded ward on the City Hospital site. The ward would be designed to reduce the requirement for critical care;
• Additional 3 Modular Theatres to provide extra capacity and to enable phased refurbishment of existing estate;
• 10 bedded Enhanced Peri-operative Care Unit for surgical patients who cannot be optimally cared for in a general ward environment but can safely avoid critical care admission.

Outpatients, diagnostics and pre-operative assessment would remain at Queen’s Medical Centre (QMC) and the Treatment Centre, so there would be no change to delivery of these aspects of the service.

In July 2022 Nottingham and Nottinghamshire Integrated Care Board (ICB) sought support for the proposals from Nottinghamshire Health Scrutiny Committee. The Committee endorsed the paper advising the ICB conduct a more targeted approach to patient engagement in respect of the relocation of elective colorectal and hepatobiliary services ensuring capturing the impact on patients with different protected characteristics.

In the longer-term, through the Tomorrow’s NUH Programme, NUH would like to create a Centre of Excellence for planned care at the City Hospital, with QMC being the main location for emergency care. During the recent phase of Pre-Consultation Engagement in March/April 2022, people were supportive of this proposal as outlined in the programme of work and evidenced in the Engagement Report outlined above.  This service move is aligned with those proposals. A full public consultation on Tomorrow’s NUH is planned for mid-2023

The aim of the engagement was to seek the views of patients on the relocation of the colorectal and hepatobiliary service from QMC to the City Hospital and to understand current experiences of patients accessing the services including communication and quality of care during their admission to surgery.

We specifically wanted to hear from patients who had recently received surgical care at the NUH colorectal and hepatobiliary service.

An online survey was developed. Hard copies were also made available, with the offer to provide the survey in other languages on request.  The opportunity to participate was proactively shared at NUH outpatient clinics, as well as being shared with Patient Participation Groups, GP practices, Healthwatch Nottingham and Nottinghamshire, Voluntary, Community and Social Enterprise sector colleagues and community groups supporting colorectal or hepatobiliary conditions.

A full breakdown of survey demographics is available in Appendix 2  

Of the 21 people who completed the survey, 20 told us their gender, 81% (17) were women and 14% (3) were men and 5% (1) preferred not to say.

Of the 22 respondents, 19 people responded with their age group which included 35 – 44 11% (2), 45 – 54 47% (9), 65 and over 37% (7) and only 5% (1) preferred not to give their age group and 3 respondents did not complete the question.

Of the 21 people who told us their ethnicity, the majority 19 were white (90%) with 1 (5%) other black background and 1 (5%) preferred not to say.  

Of the 21 people who answered the question around disability respondents stated A mental health difficulty was 5% (1), An impairment health condition or learning different 10% (2), a long-standing illness or health condition 28% (6), deaf or have a hearing impairment 5% (1) and no known impairment, health condition or learning difference 52% (11).

Of the 22 people who answered the survey asking are you a carer providing unpaid support to a family member partner or friend, 81% (17) responded with no and 19% (4) said yes they were providing unpaid support. 

This section presents the analysis from responses to the survey.

When was your surgery undertaken?

We asked patients when their surgery took place, 21 people responded.  Figure 1 shows the largest number of surgeries taking place prior to January 2020 and the least was during January 2020 – December 2020.

We also asked patients where they had received their care, 75% (15) had been to Queens Medical Centre, 15% (3) had their surgery at City Hospital and 10% (2) had been to The Park for their surgery.  

Quality of Care  

The survey asked about the quality of care that patients and carers received whilst accessing the colorectal and hepatobiliary services. 20% (4) felt that their care was excellent and 50% (10) felt that their care was good. Additionally, 10% (2) of respondents felt that it was neither good nor bad.  5% (1) felt that they had poor or very poor quality care 15% (3) during admission to surgery.

“The nurses on the ward gave great care”

“Couldn’t fault surgery at all”

Results gathered regarding the quality of care during their admission, comprised 20 responses, with 80% (16) respondents giving a positive rating for quality of care during their admission with 20% (4) having a poor experience. 

Frequency of information received

When asked about the frequency of information received from NUH staff at the time of admission 16 respondents completed this question. 25% (4) found this to be excellent and 37% (6) felt their experience was good.  Overall just over half the respondents had a positive experience with frequency in terms of communications about their surgery and 6% (1) reporting this as neither good or bad. 13% (2) respondents rated their experience of receiving communications as poor and 19% (3) people rated the communications during surgery as very poor.

16 respondents answered the frequency of communications questions with 69% (11) having a positive experience with receiving communications and 31% (5) having a poor experience receiving communications. 

Quality of information provided

We also asked a question around the quality of information that was given at the time of their appointment such as patient leaflets and letters.  18 people responded, of whom 28% (5) thought this was excellent and 33% (6) thought it was good. 11% (2) thought it was neither good or bad. 16% (3) thought it was poor and 11% (2) thought it was very poor. 

“Very little information given before the operation”

The question on quality of information given at the time of their care was answered by 18 people of whom 72% (13) had a positive experience of quality of information with only 28% (5) having a poor experience.

Rating the environment patients were treated in

We wanted to know how patients felt about the environment in which they were treated whilst in hospital for their surgery.  20 respondents answered this question. 20% (4) respondents rated the environment as excellent and 35% (7) rated the environment as good.  However, 30% (6) respondents opted for neither good or poor, and 15% (3) found the environment to be poor. 

Relocation of services and accessibility for patients

NUH is looking to relocate services to the City Hospital from QMC and will be providing new facilities.  Therefore, we wanted to find out how accessible each hospital was to patients who had previously used the service. 

Figure 2 shows the responses from patients about their experience of accessing the City Hospital (19 responses) and the Queens Medical Centre (18 responses) . By a slightly higher majority, the City Hospital was rated as the easiest hospital to access with 58% rating access as excellent or good, compared to access to QMC which 44% rated as excellent or good.

City Hospital – respondents rated the experience of accessing City Hospital as excellent 31% (6) , good 26% (5), neutral 16% (3), poor 11% (2), very poor 11% (2) and not sure 5% (1).

Queens Medical Centre – respondents rated the experience of accessing QMC as excellent 11% (2), good 33% (6), neutral 22% (4), poor 17% (3), very poor 17% (3)

“If you are going to move services here you either need to seriously improve car parking or provide adequate public transport.”

“Car parking charges are expensive”

Further comments made by patients were in support of the access to both hospitals stating that public transport was available and been accessed by patients visiting Queens Medical Centre.  However, depending on where in the county you live it could take longer to travel to City Hospital.  The comments below were made in response to this question.

“Much nearer and easier to reach”

“It is on the bus route to Queens Medical Centre”  

“I live in South Nottinghamshire and City would mean up to one hour travel time dependent on time of day”

“It is on the bus route to Queens Medical Centre“

How would you feel about having to attend a different hospital setting

It is proposed that outpatient and pre-operative clinics would remain at Queens Medical Centre, with the surgery itself taking place at City Hospital. Patients were asked on a scale of 1 – 10 whether this was a concern or whether this would not be an issue. 22 responded to this question, with responses as follows: 36% (8) stated this would not be an issue (ranking the scale from 10 – 7), 32% (7) ranked this as 5 on the scale i.e. not of concern, and 32% (7) considered this to be a significant problem, ranking it as 1 on the scale.   

Thank you to all participants who took the time to complete the survey your feedback and experience and sharing your experiences with us.

For a copy of the survey questions or all the survey results, please contact nnicb-nn.engagement@nhs.net