Dear Gareth

Comments on `Beyond HealthFit' Presentation: Health Review Committee Meeting 25 May 2004

I am writing in response to the paper presented to Hampshire County Council Health Review Committee on 25 May. The comments set out below draw on a number of themes highlighted in a lengthy discussion on issues raised in response to the presentation and are supported by the health overview and scrutiny Chairmen from Portsmouth City Council and the Isle of Wight Council. For ease of reference we have arranged these under the same headings used in the explanatory overheads.

It is important to stress that these comments are not an attempt to cut across the internal management arrangements of the NHS. The structural changes set out in `refocusing leadership' are for the Strategic Health Authority and PCTs to determine. The financial challenges facing the local health economy are however significant and it is clear that action will have to be taken to address the underlying financial deficit of £50 million. Where this has an impact on service delivery the health overview and scrutiny committees will have an interest in the changes proposed.

The points that we are raising will help members understand how `refocusing leadership' will contribute to shaping health services in Hampshire and the Isle of Wight in the future: in particular the roll out of the `HealthFit' programme which has significant implications for health service configuration across our respective populations.

You will be aware of a number of issues that have previously been raised with you in relation to `HealthFit' and other initiatives such as the introduction of independent sector treatment centres and Foundation Hospitals. These have included the need for planning processes to involve local people, service users and other key stakeholders, concerns about the integration of clinical staff teams and the challenge of achieving a balance between acute, community and primary care provision.

The specific points and questions we would wish to raise include:

1. Diagnosis of the System

· We have noted the difficult financial position of the health economy and the need for action to be taken. In this respect we would support direction set by `Refocusing Leadership', however the challenge of running the same number of organisations through an integrated management team must not be underestimated. We remain of the view that fewer organisations are required if the full benefits envisaged are to be achieved.

· The emphasis on primary care suggests that changes in commissioning will not take place until next April at the earliest. This remains a source of concern given the financial pressures facing the system.

· It would be helpful to understand the additional action being taken with acute trusts and the ambulance trust to contribute to the resolution of the current financial position. As importantly we would wish to have confirmation of any action being taken in relation to mental health services and services for older people to reduce the current deficit and promote more cost effective, streamlined commissioning that has a real potential to shift services (e.g. chronic disease management) from acute to community settings.

· A number of services have implications that go beyond the clusters proposed and will affect all of Hampshire and the Isle of Wight. How will these be managed and what will the role of the SHA be in providing leadership across the system.

· Is work in hand to improve engagement with clinicians and ensure that they are in accord about the changes required.

· Is there scope for pooling of support services, such as pay, accommodation HR and others, which are required across all NHS organisations on a wider basis than the clusters suggested, to create further economies of scale.

2. Refocusing Leadership

· Some of the clusters proposed cut across LSP areas or local authority boundaries. This would seem to be at variance with the evaluation of options that is set out in 4.7 of the `Refocusing Leadership' document considered by the Health Authority at its last meeting. We are aware that this point has already been flagged as a source of concern by a number of localities or other stakeholders and would ask that the Health Authority carefully considers these comments when deciding the final form of clusters to deliver the cost improvements required.

· Linked with the above point, and noting that that the proposed cluster populations range from approximately 210, 000 to 550,00 (based on 2002 figures)- what would the Health Authority consider to be the smallest and largest populations able to secure the commissioning leverage envisaged.

· Will the arrangements impact on joint commissioning if there is significant variation in the size of the clusters.

· You will be aware of our support for LSPs. A number of PCTs have built very effective links with their communities. How will PCT involvement with LSPs and other local initiatives be safeguarded in the proposed arrangements?

· Will the clusters envisaged be aligned to move seamlessly to Foundation Communities should these be introduced in the future.

· How will joint working on improvement plans and other initiatives that involve a range of different service providers be safeguarded.

· Could the Health Authority provide further information on patient flows in PCTs in Hampshire and the Isle of Wight.

· The clusters proposed vary from the localities set out in the `Healthfit ` discussion document. Is it envisaged that these clusters will provide new localities for driving HealthFit or will these remain as previously defined.

3. Clinical Services Transformation

· It would be helpful to have confirmation of that the 5 areas identified in `HealthFit' will continue to be the focus of service reconfiguration. In Hampshire we have only seen one locality development plan to date and that was in the early stages of drafting. This included surgical services as a specific area of action. If `Beyond HealthFit' will include additional services we need to be advised of this at the earliest opportunity.

· Is there further information on progress with the production of the locality plans and the reconfiguration of services that will result from their implementation? If not what is the anticipated timeframe for producing these. We will need to have this information in order to come to a view on the need for formal consultation.

· Our understanding is that early action will be taken in relation to maternity and neonatal services across the area but with specific reference to mid and south Hampshire. We have raised a number of issues regarding these services previously and would appreciate early confirmation of any plans to change provision in these key areas.

· There will be issues outside `HealthFit' that will be part of the service transformation process. It is essential that these proposals are consistent with section 11 duties and properly discussed with the relevant OSCs to determine the appropriate consultation process.

The final point that we would wish to add is our willingness to contribute to developing the governance arrangements of the new clusters whatever form you determine they should take. The challenges of working across different Boards and professional groups within any cluster arrangement agreed are significant and we are keen to support any process that will secure and support a locality presence in these arrangements.

I do hope you find these comments helpful and look forward to receiving your response.

Yours sincerely

Cllr Dr Raymond J Ellis C.Chem FRSC

Chairman, Health Review Committee

Cc Cllr K Thornber

Cllr F Hindson

Cllr F Charlton

Cllr I Stephens

Members of the Health Review Committee

Terry Butler

Chris Tapp

LSP leads