Agenda item

To receive a presentation from representatives of the Redditch and Bromsgrove CCG.

 

(Presentation to follow)

The Chair explained that the Redditch and Bromsgrove CCG and WAHT had asked to deliver a joint presentation on the subject of the proposed changes to acute hospital services.  This presentation was delivered jointly by the Interim Chief Officer of the Redditch and Bromsgrove CCG and the Acting Chief Medical Officer from WAHT. (The presentation is attached to the background papers that have been published separately for this meeting).

 

During delivery of the presentation the following matters were highlighted for the consideration of the commissioners:

 

·                The role of the Redditch and Bromsgrove CCG; the CCG received an NHS budget and was responsible for determining what health care services were needed for the year ahead.  Services were primarily commissioned from external providers negotiated through contract arrangements.

·                The Joint Services Review (JSR) of acute services started in January 2012.  The review process had been complex and contentious and it was acknowledged that this had taken too long to resolve.

·                In 2012 a key problem that had been identified was staff shortages in particular service areas and at certain professional levels.

·                The review had also found that some services were not providing best quality care, clinical outcomes were not as good as wanted and something better was needed.

·                The proposed revised clinical model had been reviewed over the course of the work by three independent bodies,. 

·                Since January 2016 the proposed clinical model had been reviewed further by the West Midlands Clinical Senate who had agreed to support it as the best clinical model available to the local population, taking into account the local context. 

·                Members were advised that the proposed new clinical model would cost the same to deliver as the existing model of service delivery and there was no financial saving to the CCG.

·                There were a number of key points detailed in the clinical model:

-           The principle of centralising services, such as Maternity services, at Worcester Royal Hospital.

-           The move of some services, such as Orthopaedic surgery, to the Alexandra Hospital in Redditch.  This recognised capacity issues in Worcester and would help to make the Alexandra Hospital a centre of excellence for planned care services such as surgery and gynaecology.

-           Retaining A&E services at Worcester Royal Hospital and the Alexandra Hospital (for adults).

·                Throughout the consultation process the CCG had engaged with the local community who had consistently raised transport, specifically in respect of access to services, as a concern.

·                The Independent Transport Group had been consulted and a range of options identified.

·                Car parking at Worcester Royal Hospital had also regularly been raised as a concern; as part of the proposed service changes a capital bid would be submitted to include £1.6 million for extra public parking at the site.

·                During a three month consultation a trial of demand for a hopper bus would be monitored. 

·                The temporary emergency changes that had already been introduced were designed to move patients to the locations where the experts were based in order to achieve the best outcomes for patients.

·                Whilst acute Maternity and Paediatric services had moved to Worcester Royal Hospital as part of this process outpatient services continued to be provide locally as did anti-natal care to women.

·                One benefit of centralising Paediatrics services was that GPs could directly access advice over the phone and there was the potential to reduce the length of time in which children had to remain in hospital.

·                A specialist home service and individual travel plans were being used to help children with complex problems who needed to go to hospital regularly.

·                In recent months pressure on services meant that WAHT had temporarily had to concentrate on providing lifesaving services, with less life threatening procedures cancelled or postponed.

·                There were national shortages of specialist staff and hospitals in other parts of the country, such as Herefordshire, were equally struggling to recruit staff to some of these specialisms.

·                Uncertainty about the future of hospital services had exacerbated the problems in Worcestershire in terms of recruiting specialist staff as this could deter candidates from applying for vacant positions.  At present there could be a reliance on locums.

·                Following the centralisation of some services, such as neo-natal care, staff in those areas had felt valued.

·                Alternatives to hospital admission included Ambulatory Emergency Care (AEC) whereby patients could be diverted to be seen via the outpatients department.

·                There was increasingly a focus on discharging people from hospital.  To assist with these GPs would be working in the emergency department in Worcester Royal Hospital and a “Step Down” ward would be introduced for those patients ready to be discharged who required rehabilitation.

·                Under the proposals 95 per cent of patients would continue to be treated at the same hospital as at present.

·                It was acknowledged that the temporary changes to services over the past five years had not been an ideal approach to take. 

·                Capital investment was needed in hospital services but this could not be secured until the proposed clinical model had been approved.  For this to occur, the model needed to be subject to public consultation.

·                The CCGs’ consultation process would last for 12 weeks, with all feedback received from the public being considered.

·                A final decision would be made in early May 2017.

 

Following the presentation elected Members on the Health Commission raised a number of points for further clarification:

 

a)        Capital investment:

 

Members questioned the process if capital investment was not secured after the consultation process had concluded and a new clinical model had been introduced. The proposals from the CCGs included plans to secure £29 million capital investment, though this could not be formally considered until the consultation process had concluded.  The Commission was advised that various scenarios had been taken into consideration for the end of the consultation process.  However, it would be difficult to secure the best outcomes for residents if the capital investment was not forthcoming.

 

b)        Finances

 

Members questioned the budgetary position of WAHT going forward, given that the new clinical model would not involve a reduction in costs. Members were advised that the trust was in deficit and the new model would not resolve this, though would make services more efficient and potentially result in a small level of savings.  The proposed model would be cost neutral for the Redditch and Bromsgrove CCG.

 

The commission was advised that the Trust was currently spending £20 million on locum staff, who were often employed at a premium.  Providing some certainty in respect of the future of hospital services would potentially help the trust to recruit permanent staff thereby reducing expenditure on locums and contributing to efficiency savings.

 

The Trust was projected to have a deficit of £35 million, £28 million and £20 million over the next three years respectively.  The deficit for the previous years would not need to be paid back but the Department of Health (DoH) would want to see that the Trust had a robust plan moving forward.

 

c)         Transport

 

The CCGs’ consultation document detailed the range of transportation options available to enable patients and their relations to access the different hospital sites.  Residents were urged to inform the CCGs in their feedback of their preferred transport options.

 

The hopper bus would be available to access for free during the trial.  It was anticipated that approximately one bus an hour would be in operation during this trial, travelling between Redditchand Worcester.  Arrangements once the trial had ended remained to be confirmed.  The commission was advised that the idea to introduce a hopper bus had been identified by a resident during the MP’s consultation on the future of Paediatric services in September 2016.  For this reason the bus had not been introduced when the JSR was first launched in 2012.

 

The individual travel plans for children who were frequent attendees at hospital were also discussed.  Members were advised that these would involve the provision of free transport.

 

Members requested a copy of the Independent Transport Group’s report for consideration.

 

d)        GPs at the Emergency Department

 

Under the proposed clinical model GPs would operate in the Emergency Department at Worcester Royal hospital.  In Redditch it was anticipated that GPs would be accessible at the “front door” as the general aim was to keep people out of hospital, though the model in Redditch might be slightly different to Worcester.  More action might also need to be taken with respect to GP links with the Princess of Wales Hospital in Bromsgrove for rehabilitation purposes.  

 

e)        Herefordshire and Worcestershire Sustainability and Transformation Plan

 

There was already some sharing of services between Herefordshire and Worcestershire, particularly Stroke Services.  This had occurred because there had been concerns about the sustainability of these services locally and there had been a need to pool resources to ensure that these were maintained.

 

In the long-term further consideration would need to be given to working with trusts in other areas.  The traditional model of service delivery could not continue.  Plans for the future were detailed in the Sustainability and Transformation Plan, though this was not addressed in the CCGs’ consultation papers.  It was possible that some services would be shared with other areas, not just with Herefordshire.

 

f)          Evergreen ward

 

Clarification was provided that the Evergreen ward at Worcester Royal Hospital was the “Step down” ward that had been referred to in the presentation.  Members commented that the slide in the CCG and WAHT’s presentation that referred to this was difficult to understand, particularly due to the use of acronyms, and further clarification would be helpful if similar presentations were to be delivered across the Borough to the public as part of the consultation exercise.

 

g)        Clinical Model Options

 

Members noted that originally there had been a couple of options considered for the future provision of services by WAHT, though the second option had subsequently been rejected, and the reasons for this decision were questioned.  As part of the independent review by the WMCS the available options had been considered and the clinical model proposed in the current consultation exercise had been identified as the most appropriate for patients.  No specific discussions had been held with University Hospitals Birmingham NHS Foundation Trust about the choice of the preferred clinical model.

 

There had been some concerns that the alternative model would not be able to guarantee the sustainability of services within the whole of Worcestershire and one unforeseen consequence could have been that services would then have become unsafe.  The preferred clinical model had been the subject of a trial through the temporary service changes and all of the changes were detailed in the business case.  Only approximately 10 births involving Redditch residents were taking place outside Worcestershire each month since the emergency changes to maternity services in November 2015.  There had been no reports of a change in usage patterns for the children’s emergency treatment pathway.

 

The clinical model proposed the centralisation of consultant-led maternity and inpatient paediatrics services and the WMCS had suggested that this was the best model for Worcestershire.  University Hospitals Birmingham NHS Foundation Trust do not provide either of these services.   Despite this WAHT had consulted with trusts in other parts of the region as it had a responsibility not to make changes in isolation.

 

h)        Worcester Royal Hospital – Recent Headlines

 

It was acknowledged that there had been difficulties at Worcester Royal Hospital in recent months, though there had been some exaggeration in the media about the extent of these problems.  These difficulties were not unique to Worcestershire as the whole of the NHS was struggling with pressures arising from demand for services.

 

i)          Consultation – Public Influence

 

Members questioned whether public feedback received by the CCG during their consultation would influence the final decision that was made in respect of the future clinical model for the county.  The commission was advised that there was a legal obligation to undertake consultation.  The CCG would reflect upon any ideas put forward as part of this consultation process.

 

j)          Ambulance Services

 

As temporary changes had already been made to services within Worcestershire additional funding had been made available for two extra ambulances to accommodate the extra service times.  Similarly additional funding had been provided to support ambulance services when Stroke services were centralised.

 

k)         A&E Services

 

The Health Commission was advised that the A&E service at the Alexandra Hospital would be for those aged 16 or over.  There would also be an Urgent Care Unit for patients of all ages at the site.  Severely ill children would be directed to Worcester Royal Hospital.  Despite this whilst the preference would be for children to be referred to Worcester they would be treated at the Alexandra Hospital if they self-referred and could be helped by an on-call Paediatrician, though if they were deemed to be too unwell they would be transferred by ambulance to Worcester.  Critically ill children would be referred to Birmingham Children’s Hospital.

 

l)          Surgery

 

At present orthopaedic surgery was conducted at both Worcester Royal Hospital and the Alexandra Hospital.  In the long-term the plan would be to undertake as much orthopaedic surgery as possible at the Alexandra Hospital.  This would require investment to be made in the surgical theatre at the site.

 

m)       Patient Flows

 

Members noted that in June 2015 the trust had undertaken to review patient flows and a request was made for this information to be shared with the commission.  Members were advised that University Hospitals Birmingham NHS Foundation Trust had reported that they were under pressure.  Since the temporary change to Paediatrics services in Worcestershire the hospital had received an increase of one or two child patients from Redditch and Bromsgrove in addition to the average number of children from the two districts who already tended to use the hospital on a daily basis.  Figures were requested for the consideration of Members.

 

The letter from the University Hospital Birmingham NHS Foundation Trust had reported that there had been an increase of between 9 – 12 per cent of residents from Redditch and Bromsgrove reporting to the hospital in the preceding four years.  However, Members were advised that this could represent a small number of people as the baseline figure was relatively low.

 

n)        NHS Staff

 

The Health Commission wished it to be recorded that they valued the work of all staff based at the Alexandra Hospital.  A request was made for this praise to be conveyed back to the staff, in both medical and non-medical roles.

 

Members questioned whether the various announcements of temporary changes to hospital services had exacerbated uncertainty and the potential for the trust to recruit specialist staff.  However, Members were advised that these changes could not be made permanently without an extensive consultation exercise.

 

o)        Services Centralisation  - Evidence Basis

 

Members questioned the evidence basis for the proposals in respect of centralising services.  The commission was advised that in London Stroke services had been centralised.  The outcomes and the quality of the services had improved as a consequence. 

 

In Worcestershire prior to centralising neo-natal services more locums had been used; since centralisation had occurred, the quality of services had improved.  In Maternity Services since centralisation took place the number of caesareans had reduced.  Specialists were also required to deliver particular services and it would be impractical to provide these services without those employees.  For this reason vascular services had been centralised for a number of years.  Workforce shortages were a significant issue across the country.   The Worcestershire CCGs and WAHT were arguably ahead of other areas in terms of acknowledging and seeking to address this problem; in other parts of the country there were proposals for the centralisation of services appearing in Sustainability and Transformation Plans.

 

p)        Relations with Local Authorities

 

Members questioned the extent to which the CCGs and WAHT had liaised with Redditch Borough Council and Worcestershire County Council when considering proposed changes.  The commission was advised that Worcestershire County Council had actively engaged with the process as some of the proposals would have implications for social care.  The county Council also had a statutory responsibility to ensure that appropriate transport was available.

 

Unlike Worcestershire County Council Redditch Borough Council had not been invited to take part in the programme board which had reviewed services.  However, the Leader of the Council had been briefed at regular intervals in recent months.  It was also acknowledged that Redditch Borough Council had a crucial role due to provision of particular services important to the health and wellbeing of residents, such as housing.

 

ACTIONS:

 

1)        the CCG to provide a copy of the Independent Transport Group’s report for Members’ consideration;

 

2)        the CCG to provide a copy of the business case for Members’ consideration;

 

3)        referral figures for Redditch and Bromsgrove patients to the University Hospitals Birmingham NHS Foundation Trust and Birmingham Children’s Hospitals NHS Foundation Trust to be provided for Members’ consideration.