Contact: Denise Holden ext. 7338

e-mail: [email protected]

1. Summary and Purpose

1.1. Members have asked for a regular up-date on the issues brought to the attention of the Committee and the action taken as a result of this referral. This report sets out the inquiries received, the source of this inquiry and action taken. Where appropriate comments have been included and copies of briefings or other information attached for information.

1.2. The approach adopted provides the route through which Patient and Public Involvement Forums(due to be established by 1 December) and other partner organisations (Hampshire district councils, NHS bodies, voluntary and independent sector providers and organisations that are representative of social care service users and carers) can raise issues with the Committee.

1.3. Where inquiries raised with the Committee are already subject to monitoring or other performance management activities the action taken will be focused on the local resolution of inquiries through appropriate sign-posting to the agency best placed to respond.

1.4. Where an issue cannot be satisfactorily resolved between the parties concerned then options for further action can be considered by the Committee.

2. Recommendations for Action

2.1. Chiropody Services: the action taken to continue to follow-up these services is noted and supported.

2.2. Diagnostic and treatment centres: The Committee endorses the action taken to draw the discussion points to the attention of the Strategic Health Authority and

_ welcomes the opportunity to contribute to the engagement process proposed

_ fully contributes to this work


_ actively requests that the Health Authority includes all stakeholders across the Hampshire and Isle of Wight health system in the engagement process to ensure that any proposals taken forward are in the interest of the local health service

_ shares the discussion points raised with other Local Authorities affected

_ is apprised of the Strategic Health Authority's response to the discussion points raised

2.3. Patient and Public Involvement: the status of the patient and public involvement forums is confirmed at the next meeting and will include

_ confirmation of progress with the establishment of P&PIFs at 1st December

_ details of the complaints service available to people living in Hampshire.

2.4. Choice Agenda: the Strategic Health Authority provides an up-date on progress with this agenda in April 2004.

2.5. Redevelopment of Queen Alexandra Hospital and services in south east Hamphire: This issue is included as a standing item on the Committees agenda. Links are established with Local Authority's affected by the changes proposed and lead NHS bodies are invited to provide a regular up-date on progress with:

_ Consultation on maternity services and other new service developments

_ Implementation of Local Improvement Finance Trusts (LIFT) and independent sector treatment centres

_ Progress with Queen Alexandra redevelopment

_ other issues as appropriate

2.6. Delayed Discharges: Regular reports will be provided to the Committee on progress with placing patients

2.7. Consultation on Foundation Hospitals: The Committee

_ notes the requirements relating to consultation on the establishment of Foundation Hospitals

_ is briefed on further developments to the proposed introduction of Foundation Hospitals

_ considers any joint working arrangements required should an NHS Trust move to formal consultation on this matter

_ advises NHS Trusts in its area of the consultation requirements

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents which disclose exempt or confidential information as defined in the Act.

File Location

None

Hampshire County Council: Health Review Committee 28 October

Inquiries Received and Action Taken

Topic/inquiry	Source	Action Taken	Comment
Chiropody Services- specifically access for people with diabetes Diagnostic & Treatment Centres: are there implications for community support following discharge from these units Arrangements for Patient and Public Involvement in health and the interrelationships Management of Critical Incidents and Complaints Choice agenda Redevelopment of Queen Alexandra Hospital/Services in south east Hants Withdrawal of medical assessments for people needing rehousing Delayed Transfers of Care Consultation requirements relating to Foundation Hospitals	Committee member Follow-up continuing Follow-up continuing Committee member Chairman/HA Fareham BC, Gosport BC, Committee Members Gosport BC Fareham BC Committee Members Social Services, acute Trusts, Committee members Chairman	· Initial response did not give enough detail on actual performance. Further information requested HA compiling response. · HA has confirmed new centres · Briefing note attached at B · Forums regs published (briefing attached at C) · Details of recruitment process sent to all councillors · Local network providers confirmed (attached at D) · Briefing note attached at E · Briefing note attached at F · Pre-meeting seminar arranged for 28/10 · Briefing for members attached at G · PHT response to Fareham BC attached (H) · visit to Haslar arranged 1/10 · Issues raised at joint committee meeting · Service withdrawn following retirement of consultant · Lack of consultation will mean that service will be unavailable in Gosport for 3 months · Monitoring mechanisms identified · Briefing paper at Attachment I · Information received shared with local Trusts and SHA · Regular briefing on progress with development of Foundation Trusts to be provided to members	Response to initial questions attached at A 2 DTCs already in place, 4 planned. Issues raised in briefing note raised with the Health Authority Forums should be in place with at least 7 members on 1 December Systematic review should be in place from November. Individual trusts will report progress with this. Very challenging programme with roll-out commencing from April 04 The reconfiguration of NHS in s.e. Hants is linked with the PFI bid. This is a complex process that will require an on-going presence by the Committee. Fareham and Gosport PCT were already taking action when contacted. Interim arrangements for funding medical reports identified. Longer term review of service across agency planned Regular reports on progress with placing patients to be provided to the Committee Two local Trusts North Hampshire and Winchester and Eastleigh Hospitals are eligible to apply, as s SUHT. The final form and function of Foundation Trusts remains unclear

Attachment A

Re:     Access to Chiropody Services for High Priority Patients.

Questions raised by Health Review Committee:

.           Who are the providers of service within Hampshire?

.           What are the criteria for access to chiropody across the area, including priority groups?

.           Who is able to refer patients to these services?

.           How is the performance of the service assessed to ensure that patients needs are met, including waiting times/cancelled and booked?

.           Is the voluntary sector able to provide nail and foot care for patients not considered to be priority? and

.           Is the PAL service in the PCT the correct contact point for any individual enquiries about the availability of these services?

1.         Provision of Services:

.           Within Portsmouth City PCT, Fareham and Gosport PCT and East Hampshire PCT, services are provided at each health centre, clinic and within domiciliary services as well at some PHT sites.  Treatment for people with diabetes is offered by staff trained in diabetes foot care, whilst baseline foot assessments are undertaken by a range of disciplines including, podiatrists, nurses, doctors, AHPs and health care support workers.  

.           For the North Hampshire PCT and Blackwater Valley and Hart PCT, they are the main recognised provider of services.

.           For Mid Hampshire PCT, a service level agreement exists to provide services to the population of Eastleigh and Test Valley South (excluding Romsey and Southern parishes). Southampton City PCT provides services to the southern parishes and Test Valley South.

.           For Southampton, the Southampton City PCT offers podiatry services via a range of settings within both primary and secondary healthcare.

2.         Criterion for Access:

.           North Hampshire PCT has no specific additional referral criterion.  In terms of prioritisation, a patient is formally assessed using identifiers such as (a) presenting condition (b) medical problems affecting the foot (c) pain and (d) ability for self-care.

.           Within Blackwater Valley and Hart PCT, a 32= indicator score based on the morbidity of the patient is utilised to determine priority rather than reliance on clinical determinants.

.           Within Mid Hampshire PCT and Eastleigh (North) and Test Valley South PCT, any resident upon diagnosis may have an assessment by the Podiatry service.  Ongoing care is determined by presenting morphology i.e. neurological and vascular complication, retinopathy and pre-existing foot deformity.  Criteria for access also includes juvenile diabetes and social circumstances.

.           Within Southampton City PCT, patients requiring emergency hospital care can be referred via a number of routes.  Once a patient is identified as having a risk, appropriate care pathways are established.  Patients with intermediate level problems can be offered a range of services from annual screening and foot education programmes to care on a weekly to 3 monthly basis with a tailored education plan and appropriate shoe/orthoses provision.

3.         The Referral of Patients:

.           Within Portsmouth City PCT, Fareham and Gosport PCT and East Hampshire
PCT some patients can refer themselves for assessment. Self-referral
access largely historical process associated with DHSS criteria.

·        65+

· Physical/learning/mental health disability

· Children with special needs

· Chronic disease which may compromise foot health (diabetes/rheumatoid arthritis)

Referrals will be accepted by any Health Care Professional, however access into the service is determined by the quality/appropriateness of the referral against the service access criterion determined and prioritised by the senior podiatrist on site.

.           North Hampshire PCT accepts referrals from any source.

.           Blackwater Valley and Hart PCT accepts referrals from a variety of sources and will prioritise for quick assessment if health care professionals refer for fast track, particularly in the case of biomechanics, high risk individuals or cases requiring minor surgery.

.           In Mid Hampshire PCT, Eastleigh (North) and Test Valley South PCT, the service does not operate a 'priority' type system and is not restrictive in anyway to referral from other healthcare professionals.  Many diabetics are screened routinely in their own GP practices alongside GP's and Practice Nurses.  Consultant linked clinics provide acute services at hospital sites.  Education, advice self examination and training of other healthcare professionals form the cornerstone of the service.

.           For Southampton City PCT, referrals can come through several sources, but a number of protocols exist to determine levels of risk.  Thereafter, an appropriate care pathway will be implemented.

4.         Service Performance:

.           Within Portsmouth City PCT, Fareham and Gosport PCT, East Hampshire PCT and North Hampshire PCT, Monitoring/PI's/targets limited. Assessed on waiting times andcomplaints

Risk events/critical incidents

No's of clinics cancelled/rebooked is collected for internal management but not reported/required.

Service reviewed quarterly by PCT managers.

Current total service resource equals £1.65 per head of population across these three PCT's. Twenty five thousand caseload, 800 referrals per month, 30 staff.

.           Within Blackwater Valley and Hart PCT, waiting times are continuously monitored.  Waiting times will vary dramatically between urgent and non urgent cases, with an intention that diabetic patients with a concern will be see within days if not hours.

.           In Mid Hampshire PCT and Eastleigh (North) and Test Valley South PCT, vulnerable patients are monitored/treated regularly by the service and care is audited via the 'at risk' register.  The service ensures that urgent requests from patients/referrals from Primary Health Care Teams and consultants are within 72 hours.  The podiatry service is currently establishing 'open access' clinics which will be well publicised.  Waiting times are audited weekly at all main centres.  The PCT is updated regularly.

.           Southampton City PCT undertakes regular monitoring and makes this information available in poster form, in order that patients can see how the numbers of appointments lost add additional costs to the service.

5.         Voluntary Sector Involvement:

.           Within Portsmouth City PCT, Fareham and Gosport PCT and East Hampshire PCT, Age Concern Service operate for East Hants and Fareham & Gosport; with a nominal fee of £8.  Portsmouth City Social Services do not charge for their service. All foot care staff trained by podiatry service, shared PCT facilities and ongoing supervision provided by podiatry.the voluntary sector is involved in delivering non-priority services to patients in low risk groups e.g. those not suffering from Diabetes, PVD or RhA.

.           Within the North Hampshire PCT area, Age Concern operates a small scale scheme.

.           Although there is no voluntary involvement as such within Blackwater Valley and Hart, the PCT does provide a foot care trainer who is able to undertake sessions on the maintenance of non-pathological nails to external nursing homes etc.

.           Within Mid Hampshire PCT and Eastleigh (North) and Test Valley South PCT,  Age Concern currently have an advice service in conjunction with the podiatry service in Andover. The podiatry service is also working with Age Concern and ETVS PCT to launch a service in that area.  Part of their work with Age Concern is aimed at training some of their rehabilitation assistants and health care assistants to provide a foot care service to their current patients.

.           Within the Southampton City PCT area, the voluntary sector is becoming increasingly involved.  A training programme exists and a free nail cutting kit is available within regeneration areas (SRB6 funding).  There is input to SureStart for 0-4 year olds and the PCT have a bid to become more involved in the New Deal at Thornhill.

6.         The Involvement of the PALS Service:

Although none of the PCTs involved in this exercise reported that PALS was
the first port of call regarding information on the availability of services
specifically, the Portsmouth City PCT, Fareham and Gosport PCT and East
Hampshire PCT in particular felt that it might be a lot to expect PALs to have a
detailed understanding of service availability at all sites.  In Mid Hants PCTs
and Eastleigh (North) the present main contact point is the service HQ at
Friarsgate in Winchester.  Nevertheless, each PCT recognised the unique and
important role PALs has to play in offering general advice and guidance to
enquirers and acting to signpost referrals directly to the PCTs.  Generally the
feeling is that the individual Trusts are content to be the first point for enquiries
regarding the availability of their podiatry services, although greater involvement
from PALS is welcomed.

Attachment B

Hampshire County Council

Health Review Committee

Briefing Note: Diagnostic and Treatment Centres

Introduction

The introduction of Diagnostic and Treatment Centres (DTCs) began some two years ago with the setting up of twenty sites in the NHS. The DTCs were aimed at delivery best practice in the areas of elective surgery and diagnostics. As such the DTCs provide a high volume of activity in a predefined range of routine procedures that are not affected unplanned or emergency demands.

Three of these DTCs are based in Hampshire at

· The Chase Hospital- the first PCT led DTC providing services in a community setting. Services provided include the use of GPs with a special interest, nurse-led clinics and the planned introduction of telemedicine It will also provide a pre-assessment service for the North Hampshire Hospital DTC

· North Hampshire hospital. Designed in two phases the first phase will focus on rapid diagnosis and cover a number of specialities including ophthalmology and elements of orthopaedics. Phase 2 is a new build.

· Royal Haslar Hospital-designed in two phase the first of which deals with elective orthopaedic care. The second phase, will reconfigure elective surgery onto the Haslar site and incorporate an overseas clinical team.

Next Stages

This programme was given a significant boost in early September with the governments announcement of its intention to purchase DTCs from the private sector in 26 areas. Renamed Independent Sector Treatment Centres (ISTCs) is it anticipated that the programme will provide 250,000 operations and this will be made up of 135,000 extra operations and the transferring of 115,000 operations already planned by the NHS, freeing up additional capacity in areas where there are the longest waiting lists.

The new dedicated units will be located across England and it is intended that they will offer high quality, safe, fast, pre-booked surgery and diagnosis facilities, particularly in those specialties that have the longest waiting times for patients, including orthopaedics and ophthalmology. Around £2bn will be spent over the coming 5 years and they will all be fully operational by 2005. The announcement on 12 September covers about two thirds of the total programme and it is expected that the ISTCs will rise to 100 by 2006.

The preferred bidders to run the schemes are:

Netcare UK (South Africa)
Mercury Health Ltd (UK)
Care UK Afrox (South Africa)
Anglo Canadian (Canada)
Nations Healthcare (USA)
Birkdale Clinic (UK)
New York Presbyterian (USA)

ISTCs in Hampshire

Hampshire and the Isle of Wight Strategic Health Authority wrote to the Health Review Committee in September outlining proposals for three ISTCs. On 26 September a response by 14 October was requested, in order to inform the Health Authority Board of the views of the Committee. The three proposed ISTCS are:

1. Southampton Orthopaedic Programme

It is envisaged that this programme would commence in April 2005. The programme would increase orthopaedic capacity for the population of Southampton and south west Hampshire (approximately 550,000 people). The programme will secure a range of orthopaedic activity, ranging from major joints (hips and knees) through to spinal surgery. It is anticipated that 1,800 episodes per annum would be procured from the ISTC).

The location of the ISTC is still to be determined. What is clear, however, is that there is no potential NHS site available.

The Primary Care Trust leading on the procurement of this programme is Eastleigh and Test Valley South PCT. The preferred provider is Mercury Health.

2. Havant Community and Primary Care based Diagnosis and Treatment Centre

It is envisaged that this scheme will commence in April 2005. This is a "stand-alone" scheme for national procurement. It is anticipated that the DTC would primarily serve the population of the East Hampshire (approximately 194,000) although it would be available (capacity permitting) for the populations of other PCTs on its borders.

This development at the Oak Park site in Havant is central to the PCT's strategic vision for services to ensure delivery of the access targets and to improve the quality of services by providing patient choice and enhanced access to services. The PCT's strategy is to develop capacity in primary care and to give primary care the tools to diagnose, see and treat patients. Patients' pre-operative and post-operative care would be provided away from the acute hospital site and emergency acute admissions avoided through services provided from the DTC.

The scheme will encompass a range of activities including diagnostic services, (such as ultrasound, endoscopy, fluoroscopy, echocardiography, CT scanning, phlebotomy) as well as supporting professionals with a specialist interest and an elderly care and assessment service (including elderly mental health services).

The principle of a community hospital development on the Oak Park site was subject to a formal consultation in the spring of 2003. The proposals were supported by both the Portsmouth and South East Hampshire Community Health Council and the Hampshire and Isle of Wight Strategic Health Authority.

The Primary Care Trust leading on the procurement of this programme is East Hampshire PCT . The preferred provider is not yet known.

3. Ophthalmology Diagnosis and Treatment Centre

The ophthalmology ISTC is due to be contracted from October 2003 for two years.  There is the potential for this commencement date to be delayed as some of the bidders are proposing to build a mobile unit which would mean the service would not become operational until January or April 2004.

The Primary Care Trusts in Hampshire have made a commitment to procure 700 cataract operations from the ISTC in both 2003/04 and 2004/05.  The location of the service has yet to be determined (it could for example be provided from a mobile unit, from existing NHS facilities or from a dedicated build). Early indications, however, show that the greatest need for the ISTC is along the South coast (Portsmouth and Southampton areas, and the Isle of Wight).

The Strategic Health Authority is leading on the procurement of this programme. The preferred provider is Netcare.

Discussion Points

The idea of having a facility able to deal with the areas of elective care that were experiencing the most pressures has generally been welcomed as a means of further reducing waiting times.

The introduction of private sector providers, many of whom are overseas of international is a new development, although these services will continue to be free from the patients perspective.

A number of points about the DTCs/ISTCs in Hampshire would benefit from further clarification:

These include

· The affordability of the schemes, in particular the revenue consequences that the Primary Care Trusts will be committed to. South East Hampshire is undergoing enormous change and redevelopment, which has been the cause of considerable uncertainty and anxiety for local people. The Private Finance Initiative for the redevelopment of the Queen Alexandra Hospital and the LIFT programme being developed across East Hampshire and Fareham and Gosport PCTs will have the effect of bringing additional private sector funding into the local health economy which can be used to the benefit of local people and should be welcomed. There are however long term funding implications associated with all of these schemes.

· Although there are potentially significant benefits to local people from the provision of additional capacity it must also be recognised that there could be equally significant risks should this lead to a destabilisation of NHS provision.

· The assessment of need that has underpinned the planning assumptions and the commitment required from PCTs to procure procedures from the Independent Sector Treatment Centres (ISTCs). In particular it would be helpful to have confirmation that current and planned capacity across the NHS sector is being fully utilised.

· The anticipated benefits of the programme for local people in terms of waiting times and choice. PCTs are having to balance the competing needs of primary, intermediate and acute care. The introduction of the `choice' agenda will have a further impact on the balance between these services. It is not clear if there will be an option for PCTs to disengage from a contact with a ISTC if they consider that other priorities (or patient choice) requires this.

· The Health Authority letter refers to a five year contract yet the supporting summary for the Ophthalmology ISTC refers to a two year contract.

· What funding is provide centrally to fund the programme and the proportion that comes from within the existing allocation to the Health Authority and PCTs.

· Previous discussions regarding the provision of services in Havant suggested that this scheme was being funded through LIFT. It would be helpful to have further information about how these two initiatives are linked.

· Where would the staff come from. The initial premise was that these centres would be staffed by teams from abroad. The recent briefing by the Democratic Health Network however suggests that this premise has now changed and up to 70% of staff of ISTCs may be drawn from the NHS. If this is the case then the implications for NHS Trusts need to be understood. Issues about professional development and training need to be considered in this context as well as the potential for `drift' towards the private sector compromising the capacity of NHS Trusts to deliver a full range of specialist services.

· The emphasis on short stay elective treatment will mean that NHS Trusts will need to deal with more complex or specialist cases. If the costs of care are based on an aggregated national tariff then this could have implications in terms of funding the more complex care requiring longer lengths of stay.

· It is not clear, as flagged in the last inquiry report to the Committee, how the aftercare required by people attending the ISTCs but needing to recuperate in the community, will be provided for. This point will need to be addressed as the planning process rolls forward.

· What evaluation has been carried out of the current NHS funded DTCs to establish if they are performing to expected capacity and the impact that they have on other service providers.

· As private sector providers the ISTCs will not be directly subject to health scrutiny, except through the commissioning PCTs. As a minimum it would therefore seem reasonable to expect that the suggested arrangements set out in 4.4.1 of the OSC guidance is included in any procurement arrangements. Similarly consideration needs to be given to the way in which Patient and Public Involvements Forums will operate alongside these facilities.

· The requirements applying to NHS bodies under section 11 of the Health and Social Care Act, the NHS complaints procedure and the provision of a PALs service will not apply to ISTCs. Arrangements for addressing these key issues need to be in place to ensure full and appropriate accountability to local people.

· There also needs to be clarity regarding the clinical governance and audit arrangements to be put in place, including clear quality criteria relating to performance and conduct.

The letter from the Health Authority makes it clear that the proposals are not subject to formal consultation but instead suggests that there is `comprehensive local engagement' in relation to the effect that DCT/ISTC procurement will have on existing patterns of provision and the way in which any arrangements made are to be implemented, especially from a patients point of view.

It is therefore recommended that:

· the Committee shares the discussion points outlined above with other Local Authorities and the Health Authority

· welcomes the opportunity to contribute to the engagement process proposed

· fully contributes to this work

· actively requests that the Health Authority includes all stakeholders across the Hampshire and Isle of Wight health system in the engagement process to ensure that any proposals taken forward are in the interest of the local health service

Attachment C

Hampshire County Council

Health Review Committee

Briefing Note: Patients Forums

Introduction

The Patients Forum recommendations have now been published. They can be accessed as follows:

· The Patients' Forums (Membership and Procedure) Regulations 2003

http://www.legislation.hmso.gov.uk/si/si2003/20032123.htm

· The Patients' Forums (Functions) Regulations 2003

http://www.legislation.hmso.gov.uk/si/si2003/20032124.htm

Guidance will be issued on the way in which the Forums will work, similar to that produced for the Overview and Scrutiny Function. The network providers for the Forums have been appointed. These are attached at appendix one.

It is intended that the Forums will be in place by the 1 December when CHCs are to be abolished.

Patients Forums (Membership and Procedures) Regulations

These cover:

· Membership numbers of at least 7 for an NHS Trust and for PCTs 7 plus at least one member from each NHS Trust in its area. CPPIH can also appoint additional members from `a body which represents members of the public in the PCTs area in matters relating to their health'. This will mean that at least 77 Forum members should be appointed in HCC area.

· Appointment of a chairman and deputy chairman

· Disqualification from appointment and cessation of disqualification. The intention to disqualify local councillors has been removed except where a councillor is a member of a relevant OSC or executive/cabinet. There is nothing addressing the need to take account of an individuals suitability to work with children or other vulnerable people

· Termination of tenure of office. CPPIH is able to act to remove a Forum member if it `is of the opinion that it is not in the interests of the Patients Forum or the health service that a member should continue to hold office. There is no appeal mechanism

· The appointment of committees and joint committees, including scope for the Forum to allow a committee to discharge all or some of its functions

· Funding, premises other facilities and staff which should be provided through the Commission. Staff are under the direction of the Forum members

· Discretion for CPPIH to pay travelling or other allowances

· Meeting and proceedings which are at the discretion of the Forum

· Issues in which members may have a pecuniary interest.

Patients Forums (Functions) Regulations

These cover:

· The exercise of functions and co-operation, setting out how the Forums should work together and requiring them to take account of advice issued by the Commission for Patient and Public Involvement in Health.

· The right to enter and inspect premises providing NHS care. This includes local authority premises. Whilst there should be regard to patients safety, privacy and dignity this right is stronger than that previously conferred on CHCs as it includes primary care services. The inspections should not comprise the effective provision of health services. Prisons, private sector providers and foundation trusts are not specifically included in the regulation but these services are expected to be included in the guidance.

· The need to keep annual accounts

· The right to require the NHS to produce information necessary for the Forum to carry out its functions. This has to be provided within 220 working days

· Restrictions on the provision of information to protect individual confidentiality

· Referral t the relevant OSC if the Forum considers that the PCT/NHS Trust for which it is established is not carrying out its duty under section 11. Every effort should be made to resolve this before referral. The regulations do not however refer to the option for the Forum to refer any matter concerning the health of local people as set out in the2002 act (19(m))

· The production of annual and other reports. This includes the requirement for the NHS to respond to Forum reports within 20 working days. The Forums may refer failure to respond to either the relevant strategic health authority or OSC.

· The proposed regulation relating to the capacity of the Forums to take over failing PALS has been deleted.

No reference is included regarding the appointment of a Forum member to the Trust Board.

Councillors who are not on the Executive or the Overview and Scrutiny Committee will be able to apply for a place on the Forums.

Attachment D

Hampshire County Council

Health Review Committee Briefing Note

Patient and Public Involvement Forums

Local Network Providers

Attachment E

Hampshire County Council

Health Review Committee Briefing Note

Complaints and Incident Reporting in the NHS

The Health Authority does not collect aggregated information from across its area any more. Basically each Trust has its own reporting system and there is therefore some variation in the form that reports take across the patch. Each Trust Board will however receive regular reports for both the complaints received and action taken as well as a summary of critical incidents. The action needed to respond to these is normally taken through the clinical governance committee, which should review each to identify any patterns, trends or unacceptable 'one-offs'. Reports to these committees are not usually in the public domain.

The complaints system is currently being revamped and it is anticipated that, with the advent of the Independent Complaints Advocacy Service, complaints will be able to be more openly explored (this would normally have been undertaken by CHCs). The contract for an advocacy service across the South East has been let to an advocacy group based in Hastings and the Committee may wish to keep abreast of the accessibility of these services to Hampshire residents.

At present issues of confidentiality can mean that there is very little public information produced in Trust Board papers, beyond simple numbers and response times.

Interestingly on the critical/adverse incident front, the National Patient Safety Agency will have a national reporting process in place from November this year. Patients and the public will be able to raise issues of concern with the agency. Some brief notes on the work of the agency and the reporting system which will be introduced are set out below. More information can be accessed on www.npsa.nhs.uk/publications

Although individual Trusts can be invited to provide information about how they approach the reporting of complaints and incidents this may be an issue to revisit in the future once the new systems have bedded in and the new Patients Forums are in place, perhaps kicking off with a question to Trusts (or the Patients Forum) regarding progress with the new system some time next year.

National Patient Safety Agency: An Introduction

The vast majority of NHS care is delivered to a very high standard, yet evidence shows that in complex western healthcare systems even the most dedicated and professional staff can make mistakes.

The National Patient Safety Agency (NPSA) was formed following the publication of two reports on patient safety in the NHS, An Organisation with a Memory (Department of Health, 2000), and its follow-up Building a Safer NHS for Patients (Department of Health, 2001). The reports highlighted research suggesting that around 10% of patients admitted to UK acute hospitals suffer some kind of patient safety incident, up to half of which may be preventable. Findings in the US, Australia, New Zealand and Denmark have suggested similar levels. The reports were instrumental in establishing that the NHS had to improve its capacity to learn when things go wrong.

At the National Patient Safety Agency (NPSA), we recognise that healthcare will always involve risk, but that these risks can be reduced by analysing and tackling the root causes of patient safety incidents. We are working with NHS staff and organisations to promote an open and fair culture, and to help staff inform us when things have gone wrong. In this way, we can build a national picture of the patient safety issues that need to be addressed, and greatly reduce the opportunities for error that exist in healthcare. In short, it is no longer enough to rely on the best efforts of NHS staff to provide high quality, safe care; we must improve the systems they are operating in to support them in their work.

To achieve this, we are developing a National Reporting and Learning System (NRLS), the first healthcare incident data collection system on this scale in the world. This will be rolled out across the NHS from November 2003.

Over time, the NRLS will enable NHS staff, patients and their carers in England and Wales to report any incident or prevented incident (near miss) that they are involved in or witness. The information they provide to the NPSA will be stored in an anonymous form and analysed to identify patterns and key underlying factors. This data will be cross-referenced with a number of other information sources to establish patient safety priorities, for which the NPSA will research and develop practical national solutions, together with a wide range of NHS staff and involving patients. These solutions will then be fed back to staff and organisations across the NHS to implement locally. The NPSA will work in partnership with NHS organisations to achieve this, and the NRLS has been designed to complement the vital reporting, learning and action that also takes place at a local level.

Reporting Incidents

The National Reporting and Learning System (NRLS) will provide the NPSA with anonymous data that will be analysed to identify national patient safety trends and priorities.

Why is the NRLS anonymous?
We want NHS staff to feel free to report any incident to us, and we know this will depend on staff trusting us to use that information appropriately. We are committed to anonymous and confidential reporting because the evidence from other safety critical industries such as air and rail tells us that this will maximise the number of reports we receive, and therefore the amount of learning that can take place. In addition, the NPSA does not need identifiable information for the analysis of national patient safety trends and patterns. We are interested in the `how' and not the `who'. However, we will always encourage reporters to report incidents identifiably to the organisations involved as a priority so that local learning and action can take place.

How will health professionals be able to report to the NRLS?
In time, staff in every NHS organisation in England and Wales will be able to report incidents to the NRLS though a specially designed electronic reporting form (known as the eForm) via NHS Net/HOWIS or the internet. They will also be able to do so via their organisation's local risk management system, from which incident data will be extracted and sent electronically to the NRLS. The NPSA only stores anonymous information, and does not investigate specific incidents, and this will remain the responsibility of Trusts/Local Health Boards and the appropriate NHS bodies.

How will members of the public be able to report to the NRLS?
The NPSA is committed to ensuring that the experiences of patients informs its work and priorities, and is in the early stages of developing a version of the electronic reporting form for the public and relevant third parties such as the NHS Patient Advice and Liaison Services (PALS). This is subject to extensive testing and development, but it is hoped that it will eventually enable patients and their carers to report incidents that they are involved in or witness direct to the NRLS. The NPSA also has a dedicated Patient Advice & Liaison Service team (PALS) currently taking calls from the public about their health care experiences. All reports are anonymous so that confidentiality is safeguarded. Members of the public who wish to see incidents investigated are advised to report to their local Trust or the appropriate NHS organisation.

What will the NRLS tell us?
Whenever an incident is reported to the NPSA, we will be able to see if there is a pattern or cluster of similar incidents that need to be looked into at a national level. For example, our pilot work has told us that `slips, trips and falls' are the most common category of incident reported, and that older patients are the most affected. As a result we are working on a solution to address this issue, ensuring it does not duplicate other national initiatives on this topic.

What incidents do you want to see reported?
The NPSA is encouraging the reporting of incidents that caused no harm to patients, or where harm was averted, as well as events with a serious outcome which are more likely to be flagged up in existing clinical governance and reporting systems. It is these prevented patient safety incidents (known as near misses) that can provide the most valuable learning for the NHS, because they can flag up problem areas where there is potential for things to go wrong in the future. They can also highlight ways in which staff have prevented the incident harming the patient (or have minimised the actual harm caused to the patient), and the NPSA is looking to learn from these actions to encourage the spread of best practice.

What is a patient safety incident?
A patient safety incident is defined as any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS-funded care.

The National Reporting and Learning System (NRLS) will provide the NPSA with anonymous data that will be analysed to identify national patient safety trends and priorities.

Attachment F

Health Review Committee Briefing Note

Choice Of Hospitals: Summary of Guidance to PCTs, NHS Trusts and SHAs

Summary and Purpose

This briefing notes sets out the way that it is expected that the patients choice initiative will be rolled out and the key milestones that the NHS will be working to deliver choice to all patients waiting more than six months for elective surgery.

The intention is that, by December 2005, all patients requiring elective surgery will have 4-5 choices of where that surgery is undertaken at the point that they are referred. This may include NHS hospitals locally or elsewhere, Diagnostic and Treatment Centres, private hospitals or even hospitals overseas.

Additional information on the choice programme is available on www.doh.gov.uk/choice

Timetable and Targets

By summer 2004 it is expected that all patients waiting six months for elective surgery will be offered an alternative provider for faster treatment.. Ophthalmic patients will have choice of referral from December 2004 following the elimination of 3 month waits.

Maximum waits for inpatient or day case care are expected to reduce to 9 months from April 2004 and 6 months from December 2005. The target is to achieve a maximum of three months wait for either outpatient or inpatient/day case appointments by 2008.

What patients can expect

The choice that patients can expect and the responsibilities of the NHS are set out in table form in Appendix A.

Patients that will not be offered choice will fall into three groups:

· Patients with a firm `to come in' date that ensures that will be treated before they have waited 7 months

· Clinical exclusions. There can be no blanket exclusions on clinical grounds and exclusion must be on an individual case basis. The reasons must be documented and explained to the patient.

· Exceptionally, patients needing highly specialised care where no practical alternatives exist to the provider.

Commissioning Choice

PCTs will be responsible for offering choice of hospital to patients and supporting patients in making their choices. They will be expected to appoint dedicated staff to act as Patient Care Advisors (PCAs) and commission and fund choice.

Monitoring should be in place to demonstrate:

· The numbers offered choice

· The numbers accepting choice

· Reasons for accepting/rejecting

· Exclusion

· Operations cancelled after an offer of choice

Implementation Process

The roll out of the choice programme is recommended to take place as follows

· By April 2004 30% of current eligible patients offered choice

· By 30 June 2004 60% of eligible patients offered choice

· By 31 August 2004 100% 0f eligible patients offered choice

The means by which this will be achieved across the Hampshire and Isle of Wight area will be co-ordinated by the Strategic Health Authority through a planning process that includes quality assurance, risk management arrangements, resourcing and communications.

The Committee may also wish to note the recent decision relating to the funding of treatment abroad by the NHS.

Attachment F: Appendix A

Attachment G

Hampshire County Council

Health Review Committee

Briefing Note: Redevelopment of Queen Alexandra Hospital and reconfiguration of health services in South East Hampshire

Key Points

· The round of meetings currently being held by Portsmouth Hospitals Trust (PHT) relating to the redevelopment of Queen Alexandra Hospital (QA) are more the form of an up-date on progress following the award of the PFI contract. It is unhelpful that the term consultation has been used to describe them as this is not accurate.

· The proposals originated in 1996 and have been subject to formal consultation as they have developed.

· As it stands the NHS is committed to a range of health services on Gosport peninsula. Any variation from this commitment will need to be consulted on.

· It is not clear how discussions have progressed with the Ministry of Defence. This is a particularly important point as it is not clear where the responsibility for taking forward the commitments of the old Health Authorities now rests. This needs to be pursued initially with the Health Authority

· The documentation is specific about the `hub' services and the form that the `spoke' will take on the Gosport peninsula. The form that the other `spokes' will take is less defined. From a health scrutiny perspective there needs to be clarity about the different leads for this work and the way in which it is being taken forward.

· Some proposals such as the move of the maternity services may need to be formally consulted on. A joint committee is likely to be necessary to oversee the reconfiguration programme. This would be in keeping with the section 11 requirements on involvement and would be a long term commitment although there would be likely to be peaks and troughs in work load.

· New policies (e.g. patient choice), the emphasis on local provision and advances in technology may provide opportunities for more creativity around the balance between the acute and community services

· The range and scope of services provided at Haslar need to be highlighted (hence the need for our visit). Similar issues may be emergent around the other community hospital developments Changes in practice need to be taken into account, as well as opportunities relating to the diagnostic and treatment centre.

· The commitment of the Health Authority to providing a range of services on the Gosport peninsula was confirmed on 11 May 2000. This covered:

Haslar Accident Treatment Centre (already implemented)

· Providing treatment for around 75% of patients then attending Haslar accident and emergency department, plus those attending Gosport War Memorial Hospital minor injuries unit. Estimated 17,500 patients per annum

· Located at the Haslar site (subject to MoD agreement)

· Open 24 hours a day, 7 days a week

· Staffed by nurse practitioners

· Review clinics held every weekday by A&E consultants

· X-ray facilities and monitoring equipment

· Telemedicine links to the main A&E site at QA

· Collaborative arrangements with clinical services based on the site during the transitional period

Emergency ambulance services (already implemented)

· Additional ambulance cover 16 hours a day 7 days a week to provide for extra journey time to QA

· Rapid response vehicle with paramedic 18/19 hours a day, 7 days a week, dedicated to the Gosport peninsula

· Funding for additional ambulance time to cover peak periods

· Some patients to be taken to the Haslar Accidents Treatment Centre according to protocols

Inpatient services

· Patients having hip or knee replacements, or suffering strokes to be transferred to Gosport War memorial Hospital after the initial phase of treatment in Portsmouth, for post-operative care and rehabilitation

· Additional physiotherapy, occupational therapy etc to be provided at Gosport War memorial

· All other inpatient services to be transferred to QA on completion of the redevelopment

Day Cases

· Day Surgery to be carried out at Haslar for suitable patients in good general health (approx 1100 cases per year)

· One or two theatre sessions per week for each of general surgery and orthopaedics and at least monthly for gynaecology and urology

· Endoscopy sessions at Haslar every week day

Outpatients

· More patients to be seen on the Gosport peninsula (plus 5,000) with reductions in numbers seen at QA and St Mary's

· Over 100 outpatient clinics per week on the Gosport peninsula in over 20 specialities

· Clinics to be help at Haslar and the War Memorial Hospital

Source Documentation

1. Strategic Plan 1996-2000: Care For Life. Portsmouth Hospitals Trust.

This is the source document underpinning the current position on the redevelopment of QA Hospital. Set out in three parts the document provides a detailed analysis of the starting point for the Trust, the strategic goals it wished to achieve and the future configuration of services that would achieve this vision. The progress towards the future configuration of service would be reviewed annually.

The proposals set out in the plan were subject to wide consultation at that time. The Plan includes a detailed analysis of the local demography, social and economic considerations, key policy document, competitor analysis and a

SWOT analysis.

The final conclusion of the way forward provided an outline business case in the process of securing PFI funding. Key points to come out of the plan included the focus on the redevelopment of the QA through PFI and the change of use of the St Mary's site to that of a `Community Hospital Plus'.

Haslar Hospital was seen at that time as a partner in delivery of the strategic plan with mutual benefits to be gained from collaborative working with an emphasis on the delivery of shared and complementary services.

2. Future health services for residents of Gosport and South Fareham: Portsmouth and South East Hampshire Health Authority. May 1999.

This document was produced by the Health Authority following the decision of the Ministry of Defence to close Haslar Hospital in December 1998.

This document was part of a two stage process designed to outline proposals for the most appropriate pattern of health services in Gosport, recognising the duty of the Health Authority to ensure the continuation of comprehensive health care for residents of the Gosport peninsula. Local groups and individuals were invited to comment on the proposals. These shaped the development of detailed proposals that were subject to formal consultation in January 2000.

The document contains an assurance from the then Secretary of State that he would not `accept any future NHS arrangements in Gosport that do not meet their needs' (local people).

The document notes that, at that time Haslar was providing between 50% and 60% of the hospital based services for local people. In addition it provided about 6% of emergency inpatient activity and 11% of all planned inpatient clinical activity for residents of other parts of Fareham.. In 1998 there were nearly 20,000 attendances at Haslar A&E department.

The document includes a set of guiding principles namely that services should

· provide clinically safe viable and affordable services conforming to modern practice

· ensure access to emergency and urgent treatment taking into account best practice provide services which meet the requirements of the medical Royal Collages; create medical teams able to support a full programme of clinical audit and education; and have a large enough case load where there is known to be a relationship between the size of caseload and quality

· provide services as close as is practicable to the people who need them- recognising the difficulties expense and time involved in patients travelling across the district for health care

· ensure that services are designed by looking at people needs first and buildings and organisational boundaries second share NHS facilities fairly across the whole health community

· work openly and in partnership with the NHS and with others.

3. Changes to health services for the residents of Gosport and South Fareham: Portsmouth and South East Hampshire Health Authority. January 2000.

Following the discussion document setting out the principles for providing NHS services in Gosport the full consultation document was published in January 2000.

This covered two distinct timeframes

· the services to be provided at Haslar until the completion of developments at QA

· the services to be provide on the Gosport peninsula once the developments were complete.

In drawing the document together the Health Authority worked closely with the Haslar Task Force. The consultation document proposed that as a guiding principle the maximum range of services should be provide on the Gosport peninsula, consistent with safe and effective practice. Where patients can be treated locally rather than travelling off the peninsula this will have benefits for patients and reduce the need for travel in line with the Governments transport policy.

The range of services to be made available on the peninsula included;

· the continuation of the Haslar Accident Treatment Centre,

· inpatient rehabilitation and post acute care

· day surgery

· endoscopy services

· most outpatient clinics

· diagnostic services.

Additional physiotherapy and other therapy services would be necessary to support this provision as well as enhanced ambulance service provision.

The Health Authority also considered where services should be provided on the peninsula and came to the conclusion that the preferred option would be to maintain a split of services between Haslar and the War Memorial Hospital. It was noted that this was contingent on agreement being reached with the Ministry of Defence to make available part of the Haslar site for NHS use on a long term basis. The single storey `Crosslink' block would provide the necessary space for the workload and functions proposed. In addition to the building itself the Health Authority also wished to retain all the fixed and major items of equipment associated with the cross link block including x-ray equipment and operating tables. Costing associated with the proposals were identified.

4. Report on Health Authority Consultation on Changes to Health Services for Residents of Gosport and South Fareham, January-April 2000. Portsmouth and South East Hampshire Health Authority.

This report set out the responses to the consultation on the Health Authority's proposals. It notes the high level of public response, including the strong preference for Haslar to remain as a district general hospital. This was not an option that was within the scope of the consultation. Concerns raised by local people included:

· the need for the continuation of A&E services

· difficulties with travel and traffic congestion

· lack of public transport

· parking problems at QA

· the loss of inpatient beds at Haslar

· population increases

· lack of provision of intensive care beds.

Most concerns related to issues of access to emergency treatment and transport issues.

5. Minutes of the Portsmouth and South East Hampshire Health Authority Meeting:11 May 2000.

The minutes note that the proposals were supported by the CHC (with some concerns flagged relating to transport) and the Haslar Task Force. The Health Authority then resolved that it approved the recommendations:

· to implement the changes set out in section 5 of the consultation document relating to bringing the Haslar Accident Treatment Centre and enhanced emergency ambulance service into operation on 1 August

· to transfer of the minor injuries unit at Gosport War memorial Hospital to the Haslar Accident treatment Centre

· to pursue vigorously with the Ministry of Defence discussions on the long term provision of NHS services on the Haslar site and seek to agree timescales for decisions for decisions that will secure local provision of health services beyond a five to seven year time frame

· to implement the proposed future pattern of health services identified in the consultation document to pursuer discussions with local authorities on improved transport provision for the Gosport peninsula

· to work with partner organisations to monitor the impact of the changes in services for local people with and initial formal report in April 2001

· to support the principle that the model should be extended across the health authority area.

6. Letter to Portsmouth Hospitals Trust confirming the Health Authority Decision: 18 May 2000. This confirms the decision made by the Health Authority formally to the Trust.

Attachment H

Response From Portsmouth Hospitals Trust to Fareham Borough Council

The Trust is very aware of the responsibilities conferred upon it by the new Health and Social Care Act and we are working closely with both Hampshire and Portsmouth City Overview and Scrutiny Committees on this and looking to develop relationships with other local authorities including IOW and West Sussex. The regulations and how to play them out appropriately are new to all of us and we are keen to ensure we work within them. We have been invited to attend a Hampshire OSC meeting on 28^th October, and together with local PCTs we will be giving a presentation on local plans for the NHS. This should set the scene and give people the opportunity to understand plans that to some extent are a `given' having been agreed and consulted on some time ago. This does not, however mean that there is no room for dialogue and discussion on the detail of how they are brought to fruition and this is the main purpose of the Trust's discussion document on the redevelopment of QAH. Indeed we have already identified that Maternity services is one area where more work is needed and we have started this with our PCT colleagues.

Thank you for your suggestions regarding future consultative events. We are planning a number of further presentations and discussions with key stakeholders. We are responding to a mixture of requests from interested groups and bodies e.g. resident's associations and taking the initiative in areas of concern e.g. maternity services. The redevelopment plans and a request for feedback from the public will also be featured in a community services roadshow at the Cascades shopping centre in Portsmouth in the week beginning 22 September. The Community Health Council has been hosting our more formal public meetings as they have done in the past for previous consultations. The six meetings were planned early in the process of discussion in order to allow them to prepare and ratify their report before their abolition. We are not planning to organise any further public meeting in the same way but we would be pleased to have suggestions from the council of any existing meetings or forums in the Fareham area at which the Trust could be invited to present.

Thank you for your offer of a link to your website. This would be most welcome. The address is http://www.redevelopmentqah.org.uk. If your team have any queries about our site or links to it, the best contact would be Alan Reid, the PFI project IT Officer on 02392 286871.

I note your query about the continuity of the commitments and responsibilities for the redevelopment of QAH, made by the (IOW) and Portsmouth and SE Hampshire Health Authority. The redevelopment of QAH is at the heart of the future strategy for the whole health community. The Trust is also very aware of the public concern surrounding the future provision of health services for the south Fareham and Gosport population. This was confirmed for us at the recent public meeting about the redevelopment of QAH held in Gosport. The commitment given by the local Health Authority in 2000 remains a local NHS commitment. Fareham and Gosport PCT is leading the discussions with MOD regarding the future use of the Haslar site and its place in fulfilling this commitment. In June 2002 all the new Health Organisations, the Strategic Health Authority, PCTs and the Trust undertook a full review of the plans for redevelopment at QAH. The purpose of this review was to update earlier planning assumptions and confirm that all the new organisations were committed to the plan. This was confirmed by the SHA and PCTs and therefore I can reassure you that the existing commitment from the old HA have been adopted by the new Health bodies.

In response to your seven comments:

Proposed facilities and their links to Healthfit

We believe that we will be well placed to deliver services that meet the standards and criteria that are emerging from the Hampshire and IOW Healthfit planning exercise. We are committed to supporting the development of services close to people's homes. I am not able to comment on the detail you are proposing within your letter. These proposals need discussion with Fareham and Gosport PCT to determine the most appropriate configuration of services in the Fareham community.

Car parking

2236 Car parking spaces are being planned at QAH, 664 for visitors and 1572 for staff. These figures have been informed by a traffic impact assessment. The number has been set by Portsmouth City Council as part of their outline planning consent.

The Trust is more than aware of the current problems and is in the process of enacting the `Green Transport Plan' which it has developed in response to the outline planning consent constraint on staff parking spaces. The Trust is close to finalising the arrangements for `park and ride' for staff. This will be piloted shortly and extended as demand dictates. We have also recently set a mile exclusion for staff, advising staff who work at QAH and live within a mile that they are no longer permitted to bring their cars onto site (with agreed exceptions). These sorts of measures are going to be a permanent feature of the Trust's transport policy in order to ensure adequate parking for patients and visitors.

Finances

The Standard Form NHS PFI contract requires the contract period to be the construction period plus a 30-year operating period. At the end of this time, the facilities and services included in the contract revert to the Trust.

Staffing

The situation regarding the transfer of employment of Facilities Management (FM) staff has recently changed with the introduction by the Government of the `Retention of Employment Model' (ROEM) for operational staff within 5 disciplines.

For our scheme, we anticipate that all estates/maintenance staff will transfer to the Project Company under TUPE regulations, as will managers and supervisor grade staff in other FM services. Throughout the project every effort has been made to inform and involve staff and their representatives in the project and this will continue throughout. Part of the assessment of the bids from the project companies involved ensuring that the companies would comply with the statutory requirements of TUPE.

All operational `hotel services' staff will transfer under the new ROEM regulations which means that they retain their NHS terms and conditions of service and are seconded to The Hospital Company who will manage them on a day-to-day basis.

The contract between the Trust and The Hospital Company is based on an output specification for FM services. Any shortfall in service quality against the specification will result in payment penalties. The contract is therefore designed to deter a reduction in standards as this results in payments being reduced.

Revenue costs

An increase in revenue commitment to QAH as a consequence of the redevelopment has been carefully planned as part of a financial framework for the scheme. In June 2002, part of the review, which I describe earlier in this letter, looked at this financial framework to confirm the affordability of our plans. The SHA and local PCTs confirmed that they could afford the revenue commitment to this scheme. This commitment was given in the context of their own plans for service and capital developments.

Accident and Emergency provision

Broadly the locally health community is planning to centralise specialist services such as Critical Care (Intensive care/Emergency and Trauma admissions and complex surgery) which require a critical mass to perform at their best, but to localise outpatient and diagnostic services as far as is practical or possible.

Maternity Services

I can confirm that the impact of bringing maternity services onto the QAH site has been taken into account in the traffic impact assessment.

You have raised an interesting and thoughtful range of issues which I have address for you in this letter. If there is further briefing which your Council requires, outside the overview and scrutiny committee arena, my colleagues and I would be please to arrange this, please feel free to contact my office.

Attachment I

Is consultation with Local Authority Overview and Scrutiny Committees (OSCs) and Community Health Councils (CHCs) necessary before an NHS Trust applies to become an NHS Foundation Trust?

1. This note is drafted to help clarify legal issues around consultation with Overview and Scrutiny Committees ("OSCs") and Community Health Councils ("CHCs") where an NHS trust proposes to become an NHS foundation trust.

2. There are two separate avenues through which consultation might occur, and each has different consequences. This note considers each in turn.

(i) Consultation under the Health and Social Care Bill

3. The Health and Social Care (Community Health and Standards) Bill makes provision for regulations to require consultation on NHS foundation trust applications. However, these regulations will not be in force when the first wave of NHS trusts consult. In the interim, the Secretary of State has indicated that he expects consultation to occur with a number of groups before he will support an NHS trust's application to be an NHS foundation trust. A trust cannot proceed without this support.

4. The Department has issued a note to applicants on what consultation should cover - a copy is attached as Annex to this paper.

5. The annexed note makes clear that the Department does expect applicants to consult local OSCs and CHCs before making an application to become an NHS foundation trust, on the same basis that they should engage in wide consultation with the relevant (in most cases local) health community. As you will see, the note indicates that the Secretary of State will only support applications from NHS Trusts that can demonstrate that their proposals have been discussed with those stakeholders that have an interest.

(ii) Consultation under existing legislative requirements

6. There is also a separate issue of whether existing legislation would require an NHS Trust applying to become an NHS foundation trust to consult with OSCs or CHCs.

7. As far as OSC consultation is concerned, the Local Authority (Overview and Scrutiny Committees Health Scrutiny Functions) Regulations 2002 provide that NHS trusts should consult with local overview and scrutiny committees whenever they are considering a "substantial development" of health services, or a "substantial variation" in the provision of such services.

8. The Department of Health's view is that the transition from NHS Trust to NHS Foundation Trust is unlikely to constitute "substantial" variation or development. However, the question of whether any proposal amounts to a "substantial" one in terms of the regulations is for local, and not central, determination. Each case depends both on the terms of the proposal and the configuration of services in the area.

9. The Department's expectation that NHS Trusts will consult with local overview and scrutiny committees is based on a desire to see wide consultation with key stakeholders before an application proceeds. It is the Department's view that this should occur irrespective of whether the higher threshold of "substantial" variation is achieved. It may also be desirable for OSCs to liase informally with each other to provide combined comments on the application. As an application for NHS Foundation Trust status is unlikely to constitute a substantial development or variation, the directions requiring OSCs to form a joint committee are similarly unlikely to apply.

10. Whilst an application for NHS Foundation Trust status is unlikely to constitute a substantial development or variation, any other substantial changes that are proposed by the applicant must comply with requirements to consult OSCs arising from sections 7 to 10 of the Health and Social Care Act 2001.¹

11. Applications for NHS Foundation Trust status will not fall within regulation 4(2) of the OSC regulations, which states that NHS trusts do not have to consult overview and scrutiny committees where they propose to dissolve. This is because the provisions of the Bill are drafted so that, when an NHS trust is authorised to be an NHS foundation trust, it does not dissolve. Rather, the same body continues with a new legal status.

12. As far as consultation with CHCs is concerned, there is no requirement for NHS trusts to consult under the Community Health Council Regulations 1996. These regulations require the Strategic Health Authority (SHA) to consult with CHCs where the SHA, or a PCT in its area, is considering a substantial development of health services or a substantial variation in the provision of such services. The proposal to become an NHS foundation trust is formulated by the NHS trust and not the SHA or PCT. It therefore falls outside the scope of this consultation requirement.

13. There is also no requirement for NHS trusts to consult with CHCs as a result of the NHS Trust (Consultation on Establishment and Dissolution) Regulations 1990. This is because the regulations apply only where a NHS trust is established or dissolved. As set out in paragraph 11 above, authorisation to become a NHS foundation trust does not involve dissolution of the applicant NHS Trust.

NHS FT Unit

Department of Health

September 2003

Annex

Guidance on consultation

1. The Health and Social Care Bill presently before Parliament includes a power to make secondary legislation (Regulations) prescribing consultation requirements which must be met before the Regulator can give an authorisation to an NHS Foundation Trust. The Department will be preparing these Regulations in the coming months.

2. The Regulations will not come into force in time for the first wave of NHS Foundation Trust applications. This guidance has been prepared to inform first wave applicants about the requirements for formal consultation. It is likely that the Regulations will closely reflect the requirements set out here.

3. In addition to formal consultation, applicants will also need to engage informally and seek to reach agreement locally on a range of issues including the HR strategy and the detail of the service development strategy, protected assets and services etc.

Primary purpose of consultation

4. The primary purpose of the consultation is to ensure that NHS trusts properly prepare to become NHS Foundation Trusts. The Bill has a number of mechanisms designed to incorporate representation from the local community. Amongst other things, it requires each NHS Foundation Trust to have a public membership, potentially including patients and their carers, and staff membership. The Bill also places a duty on each NHS Foundation Trust to ensure that the actual public membership of the Trust is representative of those eligible for membership. NHS Foundation Trusts may also appoint individuals from partnership organisations to be members of the Board of Governors, which is a further mechanism for local involvement.

5. In this regard, the primary aim of the consultation is to ensure that each NHS Foundation Trust has an appropriate structure. The Secretary of State will accordingly only support an application if he is confident that robust consultation has taken place during the preparatory stage. The materials submitted for consideration by the Secretary of State must demonstrate evidence of consultation with key stakeholders. Different stakeholders will have necessarily different priorities and the level and type of consultation should reflect those differences.

Other consultation requirements

6. Applicants will be aware that there are separate statutory requirements for consultation imposed by the body of health legislation. These are set out in the following paragraphs. However, as the Secretary of State needs to be assured that the local health community has been properly consulted as an NHS Trust prepares to become an NHS Foundation Trust, consultation should not be seen as the fulfilment of any minimum statutory criteria. Rather, the Secretary of State will only support applications where there is evidence of consultation with key stakeholders and the exercise should be approached with this goal in mind.

7. NHS trusts have a duty under section 11 of the Health and Social Care Act 2001 to secure that persons to whom they provide, or may provide, health services to are consulted on -

· the planning of the provision of those services;

· the development and consideration of proposals for changes in the way those services are provided;

· decisions to by made by the body affecting the operation of those services.

8. NHS trusts also have a duty to consult with local overview and scrutiny committees where the trust has under consideration any proposal for substantial development of a health service, or for a substantial variation in the provision of such a service². Where an overview and scrutiny committee feels that consultation has not been adequate, it may report to the Secretary of State.

9. Finally, NHS trusts have a duty to consult with relevant Community Health Councils where they are to be dissolved and also staff where they are being transferred to another organisation³. While these regulations do not apply where an NHS trust is authorised to be an NHS foundation trust, it is considered appropriate that both groups are consulted in the context of the current exercise.

10. Consultation by an NHS Trust in the context of an application to become an NHS Foundation Trust is undertaken by the NHS Trust in its own right, not by a PCT on the Trust's behalf.

Who to consult

11. Bearing in mind the wide range of stakeholders with a potential interest in at least some part of the application, it is suggested that applicants ensure that the consultation document is available to (and where appropriate send to):

· those members of the public who they provide, or may provide, health services to, and any other members of the public who may fall within the trust's proposed public constituency;

· MPs;

· Community Health Councils;

· local Overview and Scrutiny Committees;

· Primary Care Trusts;

· Strategic Health Authority (including Workforce Development Confederation);

· any other local NHS partners;

· other local health care providers;

· any local authority with a significant interest, including those who provide services in partnership with the NHS trust;

· any relevant university;

· staff;

· unions;

· voluntary sector organisations;

· relevant community groups;

· education and training providers.

Period of consultation

12. The Department advises that applicants should consult for a minimum of 10 weeks. This is slightly shorter than the period generally recommended by the Cabinet Office Code of Practice on Written Consultation. However, it is in keeping with the general principle in the code that, where departure from the twelve weeks is necessary, it is helpful if the broad principles have been flagged up first. NHS Foundation Trust policy has been widely debated during the passage of the Health and Social Care Bill and in many cases discussion with some key stakeholders has started locally already.

13. The Guide to Implementation (being sent under separate cover) states that applicant Trusts' service development strategy and proposed constitution should be submitted to the Department by 12 December. In order to meet this timetable the consultation period needs to end by 30 November. Consultation therefore needs to start at the latest on 22 September. Individual Trusts may wish to start consultation earlier.

Scope of consultation

14. The key issues to be addressed in the consultation document are

· the case for NHSFT status: a description of the pros and cons arising from NHS Foundation Trust status.

· governance arrangements: proposals for new governance arrangements; proposed membership community, composition of Board of Governors and Board of Directors, election processes, proposals for communicating with and recruiting members and for ensuring a representative membership; proposed roles and responsibilities of Governors, Directors and members; proposed transition arrangements for present executive team and chair.

· service development vision: a description of what the NHSFT expects to achieve in broad terms over the next five years, focussing on patient benefits rather than organisational gain. The vision for the first two years should be consistent with (and will largely reflect) developments agreed as part of the LDP process, which have been subject to consultation and agreement with local stakeholders. The vision for 2006/7 onwards can be presented in very high-level terms. It does not need to be agreed in detail with PCTs although it should as far as possible chime with the SHA view of what is required within the local health economy and reflect the financial environment of principal commissioners.

15. The consultation does not have to be on the basis of finalised proposals. Many applicants have already started discussing aspects of their proposals for NHSFT status with stakeholders: the consultation process should mesh in with this rather than running in parallel. It is entirely acceptable (and indeed desirable) for the consultation document to set out the range of options that are being considered at this stage. So for example on governance, the document might outline the basic shape of the governance arrangements and present alternatives for the size and composition of the Board of Governors.

The consultation document

16. The consultation document need not be long. All the issues to be consulted upon could be covered in a document of around 15 or so pages, the larger focus being on governance arrangements. Alternatively, applicants may wish to develop separate documents if that better suits local conditions.

17. A possible structure for the consultation document is at Annex A. This is intended as an aide-memoire for applicants developing their own document and is not mandatory.

Responses to consultation

18. Views received from those consulted should be analysed and taken into consideration when finalising proposals. Documents describing the service development strategy and proposed governance arrangements should include a description of how comments received have influenced the proposals on which Secretary of State approval is sought.

19. If reasonable views put forward by consultees are not to be reflected in the eventual proposals put forward then clear reasons as to why they have not been included should be considered and be available.

Support in undertaking consultation

20. To assist applicants DH will provide core consultation materials (guides to the policy and Q&A) for use by applicants where they wish. The first set of these has been circulated and more will be provided at a best practice session with COMMS leads on 13th August, which will cover consultation. We will also run a session on consultation processes and requirements with Governance leads on 12 August. Cabinet office guidance (http://www.cabinet-office.gov.uk/regulation/Consultation/introduction.htm) also provides more information on conducting effective consultations.

NHSFT Team

July 2003

Annex A

Consultation Document Layout

This is document provides a suggested layout for consultation documents for NHS Foundation Trust applications. It is not a requirement of the applications process to use this format; applicants are free to prepare documents in a manner that best reflects their own local circumstances.