Contact: Denise Holden ext. 7338

e-mail: [email protected]

1. Summary and Purpose

1.1. This report provides Members with information about the issues brought to the attention of the Committee and the action taken as a result of these referrals. It sets out the inquiries received, the source of this inquiry, action taken and recommendations for further action. Where appropriate comments have been included and copies of briefings or other information attached.

1.2. The approach adopted provides the route through which Patient and Public Involvement Forums (established in 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 the Committee can consider options for further action.

1.5. The recommendations included in this report support Aim 5 of the Corporate Strategy (Improving Services) through the overview and scrutiny of health services in the Hampshire County Council area.

2. Recommendations for Action

2.1. Diagnostic and Treatment Centres: the Committee receives a further up-date from the Strategic Health Authority in relation to progress with the introduction of treatment centres in March 2005.

2.2. Patient and Public Involvement:

_ the Committee notes intention to abolish the Commission for Patient and Public Involvement as part of a drive to reduce bureaucracy in the public sector. Local P&PIFs will continue. It has yet to be confirmed how they will be supported nationally. This is one of a number of changes to arms length bodies. Full details of the outcomes of the review of arms length bodies is available at: www.dh.gov.uk/assetRoot/04/08/60/85/04086085.pdf

_ That feedback from the area meetings includes participants views on key challenges facing the health economy, the main areas for health scrutiny, identification of the working relationships needed to support health scrutiny. This will be provided to members at the next meeting

2.3. Redevelopment of Queen Alexandra Hospital and services in south east Hampshire: This issue is included as a standing item on the Committees agenda

· The Committee monitors the public consultation being undertaken by Fareham and Gosport PCT. A meeting to consider the outcome of this process and the preferred option identified by the PCT is has been arranged for 21 October. Further details on this process is included in item 7

· The Committee receives a copies of the independent traffic assessment, financial analysis of the options and the assessment of health needs at the earliest opportunity

2.4. Beyond Healthfit: The Committee:

· is sent full details of the Local Delivery Agreements scheduled to be available at the end of September.

· Continues to press for full details of community engagement in developing proposals to change services

· Notes the Strategic Health Authority will be holding an event for stakeholders, including health overview and scrutiny committees in Hampshire and the Isle of Wight, on 10 November

2.5. Out of Hours Services(OOH): The Committee receives a response to the following enquiries:

· Given the experience of the Isle of Wight health economy as an exemplar in OOH provision, and the progress with providing a fully integrated model of unscheduled care, how is the learning from this being used to inform other clusters in Hampshire

· Given the significant deficit facing the NHS in Hampshire and the Isle of Wight, what assessment has been made of the costs of providing these services and is this funding available

· Is there a lead identified for taking this work forward in Hampshire and the Isle of Wight or is this being taken forward within each cluster

· What patient and public involvement will underpin the local development of OOH services. Who will lead this

· What account is taken of journey time if a patient is asked to attend a centre

· What happens if a patient does not have transport

· Is the appropriateness of referrals to 999 or A&E assessed? If so by whom

· What evidence is there that service providers are able to meet the quality standards for face to face consultations within the agreed timeframes

· What are the options for providing OOH forward within different clusters and how is this involving A&E departments, ambulance services, social services and other providers of unscheduled care

· How has the demand for these services been established to ensure that there is sufficient capacity in OOH provision

· Is demand mapped to identify peaks and troughs

· What account is taken of patients with special needs living in the community? How are these defined

· What account is taken of people receiving specialist care living in the community (e.g. people with mental health illness, people with chronic conditions, people who are terminally ill)

· What account is taken of the needs of patients who work and need non-emergency access either in the evening or at week-ends

2.6. Differential Tariffs: The Committee receives details of the response from the SHA

2.7. Foundation Hospitals: The Committee is advised of any resubmission of the applications from Hospitals in Hampshire for Foundation trust

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 that disclose exempt or confidential information as defined in the Act.

File Location

None

Hampshire County Council: Health Review Committee: 27 July 2004

Inquiries Received and Action Taken

Hampshire County Council Annexe A

Health Review Committee: 21 September 2004

Progress with Treatment Centres: Health Authority up-date

HAMPSIRE AND ISLE OF WIGHT STRATEGIC HEALTH AUTHORITY

HIOW Treatment Centre (TC) Programme: Summary of Progress at 07.09.2004

Introduction

1. The SHA is implementing an extensive range of local NHS and Independent Sector (IS) TCs supported through national TC programmes. Some are already operational (Haslar NHSTC, Chase NHSTC, National Mobile Cataract ISTC, North Hampshire Hospitals NHSTC Phase 1); some will come on stream in 2005 (Southampton and Winchester NHSTC, North Hampshire Hospitals NHSTC Phase 2, Southampton Orthopaedics ISTC, Portsmouth ISTC). This means that organisations in HIOW will be well placed to offer patients choice of treatment in modern facilities and increased plurality of provision by the 2005 target date. In addition, the TC at Lymington as part of the wider PFI scheme is scheduled to open in 2006 and additional diagnostics capacity is planned at the Oakpark Community Hospital (LIFT/ISTC scheme) for 2008. All TC capacity (NHS and IS) will be charged to PCTs at prices based on standard NHS tariffs.

2. A summary of progress on each of the TC schemes in the main programme to 2005 is set out below.

Haslar NHSTC

3. This TC, managed by Portsmouth Hospitals NHS Trust, became fully operational in May 2003 and provides mainly orthopaedics capacity with a small amount of other surgery in mixed specialties. It received capital funding of £750,000 from the national TC programme. In 2003/04 the TC used overseas clinical teams to supplement existing staffing. Additional annual capacity is around 2,150 procedures.

Chase NHSTC

4. This TC, managed by North Hampshire PCT, opened in August 2002 and became fully operational in April 2004 following a phased introduction of services. It was the first TC nationally to provide services in a primary/community care setting. The services provided are mainly diagnostics and include clinics led by GPs with Special Interest (GPSIs) and nurses and pre-assessment clinics for the North Hampshire Hospitals NHSTC. It received capital funding of £700,000 from the national TC programme. Additional annual capacity is around 700 additional procedures.

North Hampshire Hospitals NHSTC

5. There are two phases to this TC, both of which feature in the national TC programme. The first phase focused on the provision of ophthalmology and some orthopaedic services and became fully operational in May 2003. It received capital funding of around £750,000 from the national TC programme. Additional annual capacity is around 1,700 procedures.

6. The second phase is currently in development and is scheduled to become fully operational by March 2005. It will provide capacity in a number of surgical specialties and the majority of the workload will be day surgery. Work is proceeding to plan. During the building stage, each of the clinical areas at the Trust is working on re-designing services, improving pathways of care and enhancing patients' experience. Work is also being undertaken with the Workforce Development Confederation to re-design posts. This second phase is receiving capital funding of £7.5 million from the national TC programme. Additional annual capacity will be around 3,000 procedures.

National Mobile Cataract ISTC

7. All 10 PCTs in HIOW are contracted with this ISTC which is providing 900 additional procedures between February 2004 and October 2004 to help meet a maximum waiting time for cataracts of 3 months in the autumn of 2004. The ISTC is run by Netcare, one of the major South African health care providers. The mobile site used for HIOW is Haslar and over the period the mobile is visiting the site for 5 operation weeks. The contract may be extended until February 2005 to treat 60 additional New Forest patients.

Southampton and Winchester NHSTC

8. This is a joint TC between Southampton University Hospitals NHS Trust and Winchester and Eastleigh Healthcare NHS Trust and is the first combined TC development nationally. It will provide upgraded facilities at the Royal South Hants Hospital site in Southampton and a new build at the Royal Hampshire County Hospital site in Winchester. The capacity will be for a number of surgical specialties, including orthopaedics, and the majority of the workload will be day surgery. Diagnostic services, including endoscopy and MRI scanning, will also be provided. There will be an integrated booking system for the two sites. The TC is receiving capital funding of £14.6 million from a combination of the national TC programme and NHS brokerage. Additional annual capacity will be around 7,400 surgical procedures and 7,500 endoscopies.

9. The endoscopy service on the Southampton site opened in November 2003 and the Treatment Room on the same site opened for minor surgery in September 2004; the rest of the TC, at both sites, will be fully operational by December 2004/January 2005. Work is proceeding to plan. Project Board structures for the TC development are likely to change following a review and the Refocusing Leadership process.

Southampton Orthopaedics ISTC

10. The Southampton City PCT and the New Forest/Eastleigh and Test Valley South PCT Cluster are contracted with this ISTC which will provide an additional 1,800 inpatient orthopaedic procedures annually for five years from April 2005. The ISTC will be run by Capio, an independent sector health care provider already operating in the UK and with a parent company in Sweden. The ISTC will be located in existing premises at New Hall Hospital which is run by Capio and situated about 6 miles south of Salisbury. The PCTs have worked with Capio to design patient pathways which fit with appropriate clinical practice, local triage and pre-assessment systems, patient choice and booking. Rehabilitation and follow-up care for patients will be covered where required by the ISTC.

Portsmouth ISTC

11. The Portsmouth City PCT and the Fareham and Gosport/East Hampshire PCT Cluster will use capacity at this ISTC which will provide around 6,700 day case procedures and some diagnostic services for five years starting in 2005/06. The ISTC will be run by Mercury Healthcare Ltd., an independent sector provider partnered with a major TC provider in the USA. The ISTC will be located on the St Mary's Hospital site in Portsmouth. Contract close for this ISTC is scheduled for October 2004. The former Havant ISTC scheme has now been merged with the Portsmouth ISTC for the endoscopy component and the diagnostics component is still planned for development by 2008 alongside the LIFT scheme for the Oakpark Community Hospital.

Lin Hounslow

Head of Policy and Performance

7 September 2004

Hampshire County Council Annexe B

Health Review Committee: 21 September 2004

HealthFit and Beyond HealthFit: Communications with Overview and Scrutiny Committees in Hampshire, Isle of Wight, Portsmouth and Southampton: SHA response: 10 August 2004

Thank you for your letter of 14^th July, in which you raise a number of issues relating to communications between the Strategic Health Authority and the Overview and Scrutiny Committees in Hampshire, Isle of Wight, Portsmouth and Southampton. We very much regret that there have been times when communications between the NHS and the OSCs has not been as good as it could be. Nonetheless, I can assure you that we remain committed to fostering good relationships and communications and have recently agreed a number of steps that should improve the position.

Richard Samuel and Denise Holden meet regularly and at their latest meeting on August 3^rd they were joined by other SHA managers who are part of the Beyond HealthFit team. The reasons behind slower than hoped progress with Locality Delivery Agreements and plans for clinical service transformation were explored. The complexity of the issues to be addressed and the added urgency due to the worsening financial position - necessarily focussing attention on short term as well as longer term solutions, combined to leave us in a position where we are not as far forward with the clinical transformation work stream as we would have wished.

Whilst work has been slowed, some progress has been made and over the next month or so the SHA hopes to be in a position to sign off the Locality Delivery Agreements (LDA). These LDAs will set out for each of the four localities - Isle of Wight, North Hampshire (including North East Hampshire), Mid & South West Hampshire and Portsmouth & South East Hampshire - project plans for how they intend to address their priority areas for action and how patient and public involvement in the planning process will be taken forward. Each locality will share their LDA publicly through their Board meetings.

We agreed with Denise to share current thoughts around both Cancer and Surgical services at the next joint OSC meeting that was due to take place on 28^th September. Unfortunately, we understand that the meeting has been changed to 21^st September and it is looking unlikely that the clinicians we did have lined up are going to be able to come along on the 21^st. The next date we have been given is 30^th November which is some way off.

We also discussed with Denise an event the local health system intends to arrange to enable OSCs, public and P.I.F. and lay groups to examine the LDAs and agree the way forward. We are in the very early days of planning the event, which we hope to hold in early October, and will include OSC representation on the planning group. The output from this event will help to inform a second published document from the SHA in late 2004/early 2005 that will be a follow-up to the HealthFit Strategic Framework. The document will update on progress since HealthFit, set the context for Beyond HealthFit, describe the work to date and point towards next steps.

On the very practical issue of how correspondence can best be dealt with can I ask that from now on all correspondence is sent directly to Gillian Parker, Parliamentary Business Manager. Gillian will then co-ordinate the SHA response and ensure it reaches you within a reasonable time. Quite understandably, letters from the Overview and Scrutiny Committees are often long and address complex issues which means that we usually require input from a number of SHA and other NHS managers. It would greatly assist us to be much more timely in our responses if letters are sent electronically and with numbered paragraphs so that we can forward directly to the appropriate people along with a request for them to address the issues in particular paragraphs.

We are always willing to look at ways to improve communications, if you have other suggestions that you would like to make we will be happy to discuss them.

I hope you find this helpful. As ever, please do not hesitate to contact me to discuss these matters further.

Hampshire County Council Annexe C

Health Review Committee: 21 September 2004 HealthFit and Beyond HealthFit: Communications with Overview and Scrutiny Committees in Hampshire, Isle of Wight, Portsmouth and Southampton: Reply to SHA 16 August

1. Thank you for your letter of 10 August. It was helpful to have such a timely response and to have the commitment of the Strategic Health Authority to good working relationships and communications reaffirmed.

2. It is with regret therefore that I find myself having to contact you again to regarding some omissions in your reply and to clarify some points regarding the Joint Committee.

3. Turning to the point of clarification first. You will be aware that each Local Authority has its own programme of formal meetings and reviews. These vary according to local need and priorities as does the input of the Strategic Health Authority. The meeting you refer to on 3 August explored the options for reducing the reliance of the Hampshire Health Review Committee on Richard Samuel as the principle conduit for information on proposals to change or vary NHS services. Richard's contribution has been invaluable, however, this has resulted in a perception that he is able to speak on behalf of PCTs and other NHS Trusts, which is not always the case. One route for improving understanding of our role within the local NHS would be to invite the staff responsible for leading change in service provision to present their proposals to the Committee. Surgical services and cancer were areas where it was felt that early information could be shared. The meeting dates discussed in late September are those of the Hampshire OSC, not the Joint Committee. It is important that this distinction is understood.

4. As other parts of the meeting did relate to improving communications generally I suspect that this is the source of the misunderstanding. As a way forward I am therefore suggesting that, subject to the receipt of the LDAs, a meeting is arranged to which all members of OSCs in Hampshire and the Isle of Wight can be invited. This will provide a genuine opportunity to explore the implications of these proposals for our respective populations as well as ensuring that a clear and consistent message is communicated. Your thoughts on this as an option would be appreciated.

5. Turning to the points from our letter that were not addressed in you letter

5.1. You have not given an indication of when you intend responding to the recommendation of `HealthFit' sent to you by the Isle of Wight Committee last January

5.2. How will the needs of our respective populations be identified to inform and shape plans as they develop. If this information will be included in the LDAs, together with information on the process of engagement as required under section 11 of the Health and Social Care act 2001, this needs to be confirmed and communicated to the locality leads. I must emphasise that the reference in your letter to the LDAs being made available to the public via Board meetings does not constitute the evidence of engagement that we will be seeking.

5.3. Similarly we have asked that any change to acute service reconfiguration takes account of the impact this will have on care provided in primary care and acute settings. Issues of access and equality will be of particular interest in this respect

5.4. How will service configuration issues that transcend localities be managed

6. We remain unclear about the clinical areas that are now being targeted in `Beyond HealthFit' but will wait until we receive the LDAs for clarification of the form that these will take. I understand that you are expecting these to be available at the end of September.

7. A final point that was not included in you letter was the suggested maximum of 28 days for responding to issues raised by the OSCs, with the option to request an earlier reply if this was appropriate. This proposal was discussed at the meeting on 3 August and is one that I would welcome. I will ask the other OSC chairmen for their views at the next Joint Committee meeting.

Cllr Dr Raymond J Ellis C.Chem FRSC

Chairman, Health Review Committee

Cc Cllr Ian Stevens

Cllr Fred Charlton

Cllr Brian Parnell

Martin Day

Alistair Drain

Richard Samuel

Gillian Parker

Hampshire County Council Annexe D

Heath Review Committee: 21 September 2004

Refocusing Leadership - Beyond HealthFit: SHA Up-date 27 July 2004

Now that the new Primary Care Trust clusters have been finalised and the first round of appointments for the Chief Executives held, I wanted to take a moment to set out exactly where we are in Refocusing Leadership in the context of the Beyond HealthFit programme. I recognise that the communications about the elements of the final decisions came out at different times and I wanted to ensure you have all seen and understood the full picture.

The first stage of recruitment has been completed. On the back of the PCT cluster agreements we have also reached an agreement on the future of a range of services between Winchester and Eastleigh Healthcare Trust (WEHT) and Southampton University Hospitals Trust (SUHT) and between WEHT and Mid Hampshire PCT. Until now there have been difficulties in agreeing a strategic direction for this part of Hampshire and the Isle of Wight SHA. This way forward was part of the wider Beyond HealthFit Programme but this early resolution is very welcome.

The Refocusing Leadership initiative is one part of the wider Beyond HealthFit programme - an ambitious two-year programme of work which will deliver solutions to some of our challenges of providing high quality, sustainable and safe healthcare, with patients at the heart of the service, at costs we can afford. Financial viability is crucial.

The other elements linked to Refocusing Leadership in the Beyond HealthFit programme are process improvement, clinical transformation and financial recovery.

The Refocusing leadership element of the whole system recovery was designed to increase leadership capacity and specialist expertise within PCTs; reduce complexity, improve the way in which the local health system works and develop common approaches where appropriate while still retaining a local focus.

Single management teams for clusters of PCTs were agreed and a recruitment process to appoint chief executives for the new clusters took place two weeks ago. It has been agreed that:

_ A single management team will be created for North Hampshire and Blackwater Valley and Hart PCTs. Debbie Glenn, currently chief executive of BV&H, has been appointed as cluster Chief Executive and she will take over the new role shortly.

_ There will be a single management team for East Hampshire and Fareham and Gosport PCTs. It has been decided to go out to national advertisement to recruit a chief executive for the cluster role. In the interim, Ian Piper, currently chief executive of Fareham and Gosport PCT has agreed to lead. This does not preclude him from application for the substantive post.

_ There will be a single management team for Eastleigh and Test Valley South and New Forest PCTs. John Richards, currently Chief Executive of ETVS, has been appointed to lead this cluster.

_ Under the leadership of Chief Executive Chris Evennett, Mid Hampshire PCT's role will now involve much closer working with Winchester & Eastleigh Healthcare Trust (WEHT) to develop an integrated care service for the medical management of chronic diseases; the PCT will also lead commissioning at WEHT for all PCTs, develop their existing role leading specialist commissioning across Hampshire, Isle of Wight and neighbouring areas and, subject to agreement with the other clusters, lead commissioning for mental health, learning disabilities and continuing care across Hampshire and the Isle of Wight. MH PCT will work closely with the ETVS and New Forest cluster to carry out functions only once where this is more efficient.

_ Following their bids for Foundation Trust status, now temporarily on hold, both WEHT and Southampton University Hospitals Trust (SUHT) have made some real strides forward and agreed there should be a common surgical service, led by SUHT across the whole patch. This is in line with both Trusts' vision for the future described in their FT applications. They will shortly be considering how to jointly appoint a clinical director for this service.

_ The development of a single surgical service across the SW Hampshire locality and the linkage with Mid Hampshire PCT over the medical management of chronic disease heralds a new and significant development in health services at Winchester. These changes will alter the pattern of health care delivery for the population and help ensure that the local NHS can meet the many challenges that it faces in providing high quality, efficient and affordable services to local people.

All this is positive progress and represents a significant step forward in the Refocusing Leadership work.

The process has been and will continue to be difficult for organisations and individuals and we are aware of the significant challenges being faced. It is encouraging to see how organisations have come together to tackle the key challenges facing us in implementing plans for a 21^st century NHS. With the support of the SHA, this will require all management teams collaborating and doing business in different ways, not just those involved in re-focusing leadership. We believe clear, focused leadership offers the greatest opportunity to secure health services for the future that are sustainable, affordable and meet the needs of our local populations.

More information on next steps, particularly around HR implications for affected staff, will be coming out very shortly.

If you have any questions about the process or what happens now, do please feel free to contact the SHA's Chief Executives office on 023 8072 5404 or email [email protected]. Alternatively you can contact Denis Gibson, Chief Executive of the Workforce Development Confederation (WDC) on 01962 893740 or Yvonne Coventry, Head of HR Modernisation at the WDC on 01962 893751.

Hampshire County Council Annexe E

Health Review Committee: 21 September 2004

Briefing Paper: Out of Hours Services

Introduction

1. At the last meeting of the Health Review Committee a document from the Strategic Health Authority on Out of Hours (OOH) services was shared with members. This set out the current position for the delivery of services through identified cluster groups.

2. Members of the Committee have identified a number of issues of concern relating to OOH services. The recent publication of the inquiry into OOH undertaken by the Health Select Committee has clarified the potential impact of changes to these services and some of the issues that the Committee may wish to follow-up more locally.

3. This paper summarises the findings of the Select Committee, sets out the response to initial questions raised by members and highlights areas where further information may be of interest to the Committee.

House of Commons Health Select Committee Findings: July 2004

4. The Select Committee launched a short inquiry into the potential impact of the new GP contract on the provision of OOH in May 2004. This included an assessment of the implications for other services of the changes, financial considerations and skill mix issues. The conclusions and recommendations of the Committee are attached at Appendix One. The full report can be found on http://www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/697/697.pdf

5. The OOH period is currently defined as from 6.30 pm to 8 am Mon to Friday, all weekends and all public/bank holidays. As such it covers two thirds of every working week.

6. As well as securing medical cover outside the core working hours of GP services it also acts as a mechanism for managing demands placed on accident and emergency services, including ambulance services.

7. The Carson report, published in 2000 identified a model of OOH care in which PCTs developed a network of unscheduled care provision, bringing together OOH providers to work collaboratively with other health and social care providers.

8. The BMA estimates that 90% of GP will opt out of providing OOH cover by January 2005.

9. The findings of the Committee included

· The variable state of PCTs in readiness for taking on OOH responsibilities, and, in some circumstances that this transition is being managed by junior or inexperienced staff

· The need for an integrated and collaborative approach to unscheduled care across health economies. For example links with A&E, ambulance services, minor injuries units, walk-in centres, community hospitals, social services and NHS Direct to make sure that patients see the most appropriate healthcare professional for their condition

· The need for greater patient and public involvement in redesigning OOH services

· The need for patients to receive the medication they needed at the same time and in the same place as the OOH consultation.

· The time lag between the changes to OOH and the establishment suitably trained alternative health professionals. GPs from within the existing workforce will therefore be relied upon to provide the bulk of OOH provision the short to medium term. The availability of this workforce, and the impact of pressures from the European working time directive, has not been established

· The capacity of NHS Direct to provide the single telephone point for OOH care and advice before 2006

· The need for arrangements to be in place to provide primary care services on Saturday mornings. Anecdotal evidence that other services were being impacted on where OOH changes had already taken place, especially on Saturdays when local surgeries are now closed.

· Financial pressures on PCTs and a shortfall in funding to provide the new services and the impact this may have on the quality of service

10. In summary, although the report identifies a number of opportunities linked with the changes, the speed of implementation and funding implications represent significant risks that need to be managed.

Queries raised on behalf of Members

11. The Strategic Health Authority was approached for further information in relation to additional queries raised on behalf of members. These generated the following response

· All OOH will be from 6.30pm until 8am Monday to Friday and 6.30pm Friday until 8am Monday. A variety of cover will be provided via GPs, nurses, paramedics, emergency care practitioners, walk in centres, primary care centres and visiting services. Each patch has a GP led service supported by a variety of other professionals. Some cover will be by the PCTs, some by external organisations, agencies, co-ops and commercial providers.

· No staff are being employed from other European countries, however some PCTs are commissioning services from agencies (MTS - Medical Transfer Services)that do employ GPs from Europe. There has been national media coverage of MTS but the PCTs concerned have been meticulous in ensuring those GPs who will be working locally, are registered and have all the required scrutiny/checks before starting.

· All GPs will have equitable access to patient information

· With regard to quality assurance, each cluster will have or is developing clinical governance guidelines. In addition Medical Directors are in post and have performance audit and review policies and procedures in place to monitor the service in line with the Carson standards.

· Regarding concerns about Primecare (Southampton), a full and rigorous accreditation of Primecare took place in May. Primecare have been accredited until 30 June 2005

12. The Strategic Health Authority declined to provide the Committee with the cluster plans for OOH provision. Each cluster leader has therefore been approached for this information and 4 quarters monitoring report from each of the deputising services.

Further Information to be provided to Members

13. Members are invited to consider whether they may find the following information of interest.

i. Given the experience of the Isle of Wight health economy as an exemplar in OOH provision, and the progress with providing a fully integrated model of unscheduled care, how is the learning from this being used to inform other clusters in Hampshire

ii. Given the significant deficit facing the NHS in Hampshire and the Isle of Wight, what assessment has been made of the costs of providing these services and is this funding available

iii. Is there a lead identified for taking this work forward in Hampshire and the Isle of Wight or is this being taken forward within each cluster

iv. What patient and public involvement will underpin the local development of OOH services. Who will lead this

v. What account is taken of journey time if a patient is asked to attend a centre

vi. What happens if a patient does not have transport

vii. Is the appropriateness of referrals to 999 or A&E assessed? If so by whom

viii. What evidence is there that service providers are able to meet the quality standards for face to face consultations within the agreed timeframes

ix. What are the options for providing OOH forward within different clusters and how is this involving A&E departments, ambulance services, social services and other providers of unscheduled care

x. How has the demand for these services been established to ensure that there is sufficient capacity in OOH provision

xi. Is demand mapped to identify peaks and troughs

xii. What account is taken of patients with special needs living in the community? How are these defined

xiii. What account is taken of people receiving specialist care living in the community (e.g. people with mental health illness, people with chronic conditions, people who are terminally ill)

xiv. What account is taken of the needs of patients who work and need non-emergency access either in the evening or at week-ends

Out of Hours Care Annexe E: Appendix One

House of Commons Health Select Committee

Conclusions and recommendations

1. Our evidence suggests that while PCTs across the country are in varying states of readiness for taking on responsibility for providing GP out-of-hours services, forward planning is taking place and support systems are available. However, we were concerned at reports that this critical transition was in some circumstances being managed at too junior a level within PCTs, and also that some PCTs were failing to think about more integrated approaches within their wider local health economies. We urge the Department to consider these concerns raised in our evidence in their support and management of PCTs, and also to encourage, where possible, a greater degree of public consultation and involvement around the redesigning of GP out-of-hours services, as our evidence suggests that this has so far been largely lacking. (Paragraph 21)

2. We are impressed with the potential of some models of GP out-of-hours service provision, including integration with ambulance services and creative use of skill mix. However, some of the models we have seen seem to be predicated on well developed collaborative working relationships with successful existing local out-of-hours service providers, and we urge the Department to encourage such collaborative working wherever possible. (Paragraph 32)

3. We look forward to the publication of the guide for PCTs and providers to be issued in Summer 2004, and recommend that it makes mandatory scope for the provision of medication, where necessary, at the same time and place as out-of-hours consultation. (Paragraph 40)

4. In our view, existing GPs, including those who work in co-operatives, will continue to form the backbone of future provision of out-of-hours services. They are also the NHS's main source of expertise in this complex area, and yet the availability of the GP workforce for out-of-hours cover still remains uncertain. It is therefore vital that they do not become disengaged from the process of redesigning GP out-of-hours services during this critical transition phase, and their expertise and local knowledge lost. We recommend that the Government should take all reasonable steps to encourage PCTs to work collaboratively with GPs, including those in co-operatives, and to encourage PCTs to provide the flexibility and support, as well as the financial

incentives, necessary to retain a motivated GP workforce. (Paragraph 53)

5. We strongly support the better use of skill mix to deliver out-of-hours care, not only for its potential to relieve pressure on GPs and deliver cost savings, but also, more importantly, for its potential to deliver a better quality of service to patients. However, out-of-hours care is a complex service to provide, and health professionals other than doctors will need appropriate training if they are to deliver it to a high standard. Our evidence suggests that those working in the NHS are well aware of the difficulties attendant upon recruiting and training this new workforce, and we urge the Government to ensure that PCT forward planning allows sufficient time for this to take place, and takes account of the view that triage by the most experienced clinician available, who may or may not be a doctor, is the most effective use of

resources. (Paragraph 62)

6. We accept the value of a single telephone access point for patients for all out-of-hours services. However, NHS Direct will have substantially to increase its capacity in order to cope with this burden. We remain concerned that full integration of NHS Direct and GP out-of-hours services could introduce unnecessary delay and increase referrals to other parts of the NHS. We recommend that alongside their work to develop capacity, NHS Direct should work collaboratively with others, including GPs, involved in delivering nurse telephone triage services for out-of-hours care to develop and refine their referral protocols to ensure this does not happen. (Paragraph 78)

7. GP out-of-hours services provide only one of many routes for people needing urgent care. Out-of-hours services are part of a larger network of `unscheduled' care providers, which can include emergency ambulances and A&E departments, as well as GP emergency clinics run during the day. If one of these services is withdrawn or changed, or access becomes more difficult, demand for urgent care will simply increase in other parts of the system. It is not surprising, therefore, that A&E departments are anxious that changes in the provision of GP out-of-hours services may impact on already rising attendance rates. (Paragraph 86)

8. We deplore the loss of GP Saturday morning surgeries which will limit access to their GP for many working people, and we recommend that PCTs should provide such clinics in primary care centres or co-located emergency departments. (Paragraph 87)

9. Accessing healthcare outside normal working hours can currently involve

negotiating a maze of different services and telephone numbers. We agree that in the long term, services should be designed around patients, taking account of where local patients are most likely to access healthcare. We are encouraged to see this already happening in certain places, through, for example, the co-location of primary care centres and A&E departments. However, we also believe that there is a place for patient information campaigns in order better to equip patients to play an active role in their own healthcare. Clear information should be available to everyone who needs it, setting out what local NHS services are available where, in order to help

patients make informed choices on how to access out-of-hours healthcare. We

recommend that the Government takes steps to ensure PCTs proactively provide information on NHS services to their local populations on a regular basis, paying particular attention to the need to keep people informed of any changes that may occur as a result of the handover of responsibility for out-of-hours care. (Paragraph 88)

10. Although providing services to community hospitals is a separate issue from GP out-of-hours services, it certainly seems possible from the evidence that we have heard that the handover of responsibility for GP out-of-hours services from GPs to PCTs will prompt some GPs to re-evaluate and perhaps to withdraw the services they currently provide to community hospitals, as part of their on-call duties. In our view it is regrettable that this vital subset of GPs' work has not been addressed more swiftly, and we urge the Government to ensure that this is resolved as a matter of urgency to ensure that the extremely valuable service provided by community hospitals is not jeopardised. (Paragraph 94)

11. While we do not feel that we are in an appropriate position to make

recommendations on the necessary funding levels for GP out-of-hours services and how this should sit with PCTs' other spending priorities, it is clear from our evidence that there is anxiety in many quarters about securing adequate funding for GP out of- hours services. Furthermore, with the true cost of GP out-of-hours services having been largely disguised until now by GPs' previous practice, this is essentially a `new' cost for the NHS, and one for which there are few precedents for commissioning or providing. In the light of this, we recommend that the Department monitor closely the financial arrangements for funding GP out-of-hours services. We will continue to investigate this in future years as part of our annual Public Expenditure Inquiry. (Paragraph 107)

12. We support the introduction of quality standards for all providers of GP out-of-hours services, and we hope that these will be rigorously audited. Providers should also be encouraged, through incentives, to exceed quality standards and work towards continuous improvement. We are concerned by reports that financial pressures may adversely affect the quality of services some providers are able to offer, and we recommend that a broad-brush assessment against current quality standards is conducted prior to the handover of responsibility to PCTs, in order to provide a baseline against which performance under the new system can be measured. (Paragraph 111)

List of abbreviations

A&E Accident and Emergency

BAEM British Association of Emergency Medicine

BMA British Medical Association

ECP Emergency Care Practitioner

GMS General Medical Services

NAGPC National Association of GP Co-operatives

PCT Primary Care Trust

PMS Personal Medical Services

RCGP Royal College of General Practitioners

SHA Strategic Health Authority

Hampshire County Council Annexe F

Health Review Committee: 21 September 2004

Inconsistencies in Commissioning Tariff: SHA response to Member Query, 26 July 2004

When we met in March I agreed to write to you concerning the issues you raised about potential inconsistencies in commissioning tariffs between the Southampton Primary Care Trusts (PCT). May I begin by apologising for the long delay in responding.

You are right to contend that certain inconsistencies in prices for commissioned care have been identified. You may be aware that notional prices are derived from dividing baseline funding by volumes of agreed activity. Where an individual PCT applies a `middle ground' of the cheapest prices to their activity, it can result in a value which is less than that previously agreed.

The predominating technical driver to this issue is the fact that the financial denominator in the price calculation is the historic baseline value of the Service Level Agreement. There are a number of exceptional factors that could lead to different financial baselines between PCT's. These include, the dis-aggregation of fund holding budgets, the agreement of baseline activity being disconnected from the financial value and PCT allocations being based on a capitation formula rather than a share of business basis.

The SHA became aware of this issue for the first time in a conciliation meeting between New Forest PCT and Southampton University Hospitals Trust in December 2003 (which led to formal arbitration in January 2004). The SHA were asked to intervene even though the Service Level Agreement had only been concluded following SHA involvement in August 2003, at which point the tariff issue was not recognised.

As part of the overall decision the SHA found that although there were differences between PCT prices, the calculations were reasonable and in accordance with the agreed Service Level Agreement. In addition, the process within Payment by results would gradually erode this financial variance and will ensure that, over time, all PCT's will pay the same price for services. It would therefore be inappropriate to take action at this point in time when there is an agreed national process in place to rectify the issue.

If any of this requires further clarification, please do not hesitate to contact me.

Hampshire County Council Annexe G

Health Review Committee: 21 September 2004

Inconsistencies in the Commissioning Tariff: Response to the SHA

1. I am writing in reply to your recent letter relating to the variations in the tariff charged to PCTs commissioning services from Southampton University Hospitals.

2. I am aware of the complexities of the commissioning process and the difficulties in managing the financial arrangements supporting this. I am concerned however that, given the deficit that the NHS in Hampshire and the Isle of Wight is struggling to manage, local people are not disadvantaged by the need for individual PCTs to pay more for the services they commission from the same provider. This creates the potential for inequitable access to services which I am certain you would not wish to support.

3. I was surprised to note that, even though the SHA is aware of the situation, that it is considered to be acceptable to allow this variance to continue, particularly during this financial year. Although I accept that the move to payment by results will address this issue over time the fact is that this process will not be fully implemented until 2008. In the meantime the PCTs that are disadvantaged by this arrangement will need to identify very challenging efficiency savings in other areas. My concern remains that this may impact adversely on community and primary care provision at a time when we should be seeing these services developed to support local communities.

4. I am therefore writing again to ask you to more fully consider the scope of the SHA to take action to support PCTs in addressing this issue, as a minimum to ensure that these variations do not contribute to the financial deficits that PCTs need to manage.

5. I would be grateful for your comments by 9 September.