Contact: Denise Holden ext. 7338

e-mail: [email protected]

1. Summary and Purpose

1.1 The purpose of this briefing paper is to provide members of the Committee with a summary of the key issues relating to the current consultation by Fareham and Gosport Primary Care Trust (PCT) regarding arrangements for providing NHS services to people living in Fareham and Gosport. It sets out the role and responsibility of the Health Review Committee in considering these issues, the role of the PCT and the key questions that members may wish to explore further with the PCT or key stakeholders.

1.2 The interest of the Committee in responding to the proposal is two -fold

1. Is the Committee satisfied with the content of the consultation and that sufficient time has been allowed

2. Is the preferred way forward in the interests of the health service in the area affected

1.3 A select committee approach has been adopted to consider this matter. This provides an opportunity for the PCT to set out the case for change and for key stakeholders in Fareham and Gosport to share their views on the proposal and consultation process.

1.4 The format of the meeting will enable members to hear different views about this complex issue and understand where differences exist before finalising any recommendations that they may wish to make to the PCT.

1.5 The Board of Fareham and Gosport PCT forward will take the final decision on the way forward on 15 December 2004. It is anticipated that the Board will respond to any recommendations made by the Committee at this time. If the Committee is not satisfied with the response of the PCT, the option remains for the decision of the Board to be `called in' for formal scrutiny. If any outstanding issues cannot be resolved locally the matter may be referred by the Committee to the Secretary of State for Health.

1.6 This report supports Aim 5 of the Corporate Strategy (Improving Services) through the overview and scrutiny of health services in the Hampshire County Council area.

2. Conduct of the Meeting

2.1 The regulatory framework within which the Committee must function is described below. It will be important for members, and those attending the meeting to be aware of the limitations that this places on the action open to the Committee when considering the proposal from Fareham and Gosport PCT.

2.2 Key stakeholders in Fareham and Gosport have been invited to share their views on the proposal either at the special meeting or in writing. The Committee has invited specific feedback on:

· The consultation process, this may include any issues relating to timing and content, or the way in which the views of local people have shaped the development of the preferred option

· The preferred option identified by the PCT; this may include factors relating to the health needs of local people or the proposed configuration of services. The Committee will be particularly keen to hear of any outstanding issues that key stakeholders consider have not been addressed and the factual basis on which these are based.

2.3 The presentations to be provided to the Committee will be managed to ensure that each of the stakeholder organisations has an equal opportunity to share their views. The time slots allocated will be strictly adhered to, although actual timings for the day will be dependent on the deputations received and questions asked after each presentation. Questions will only be taken from Committee members.

2.4 Any written comments to be made to the Committee will be available to members, together with any supporting information provided, at the meeting on 26 November 2004.

3. The Role of the Health Review Committee

3.1 The statutory framework within which the Committee functions defines the areas that it is able to consider when responding to formal consultation from the NHS. For the purposes of this discussion the interests of the Committee exists at two levels:

1. Is the Committee satisfied with the content of the consultation and that sufficient time has been allowed.

2. Is the preferred way forward identified by the PCT in the interests of the health service in the area affected.

3.2 If the Committee determines that the consultation process is has not been satisfactory, or concludes that the preferred option is not in the interests of the health service in the area, then it can make recommendations for addressing these issues to the NHS body concerned. Although the Committee does not have the power to make decisions or require others to act, it can request that the NHS bodies concerned responds in writing to any recommendations made. If the Committee is not satisfied with the response from the PCT, and has exhausted all options for local resolution, the matter may be referred to the Secretary of State for Health.

3.3 In coming to a view on these two issues it is essential that the Committee specifies the grounds on which any conclusion is reached. This may require that the Committee balances the `expert' opinion provided and the public views expressed. As different stakeholders may have different views on a particular proposal the Committee will need to understand the rationale or evidence that has informed the different perspectives presented.

3.4 If, having heard from the case for change from the PCT and key stakeholders, the Committee does not support the proposal, the reasons for this and the supporting evidence, must be clearly stated. Should the Committee wish to refer the proposal to the Secretary of State this information will inform the decision on any further action to be taken.

4. The Role of the PCT

4.1 There are three core functions for PCTs:

· to develop primary and community health services

· to commission specialist health services for their population

· to improve health in their community and tackle health inequalities (Source: Commission for Health Improvement: Primary Care Trusts Sector Report 2004)

4.2 The responsibility for commissioning services has evolved rapidly to include most hospital and other specialist services. Consequently, PCTs should be actively deciding what healthcare to buy from which organisations (not necessarily NHS) and should be monitoring the quality. Theoretically, PCTs have enormous power to reshape local health services should they choose to do so. They are also required to improve health and tackle health inequalities in their area.

4.3 In carrying out their functions PCTs are expected to ensure proper stewardship of public money and assets. This includes responsibility for:

· the propriety and regularity of the PCT's finances

· keeping proper accounts

· prudent and economical administration

· avoidance of waste and extravagance, and

· the efficient and effective use of all resources. (Source: A Guide to the NHS for members and officers of health scrutiny committees. Department of Health. November 2003)

5. Background Information: 1999-2003

5.1 The lead up to the current consultation by Fareham & Gosport PCT has been complex and of intense public interest. This was initially generated in December 1998 by a decision of the Ministry of Defence (MoD) to close the Royal Hospital Haslar (RHH) as part of the review of the needs of Defence Medical Services. At this time an assurance was given that RHH would remain open until replacement services were available. The MoD also announced its intention to establish a MoD Hospital Unit at the Queen Alexandra site.

5.2 The pattern of services provided by RHH at that time was identified by the Portsmouth and South East Hampshire Health Authority as:

_ between 50% and 60% of hospital based services for the residents of the Borough and Gosport, and the residents of Stubbington and Hill Head in the Borough of Fareham

_ 6% of emergency inpatient activity and 11% of all planned clinical activity for residents from other parts of Fareham

5.3 The analysis of the use of the accident and emergency department published by the Health Authority in May 1999 suggested that within a population of 100,000 (the approximate civilian population with the catchment area of RHH), 24,000 attendances at the Accident and Emergency Department could be anticipated of which more than 50% could be treated by trained nurse practitioners.

5.4 Other services discussed with local people at that time included outpatient and diagnostics, non-acute inpatient services and enhanced ambulance cover. This was set against the backdrop of major acute and emergency services being transferred to the redeveloped Queen Alexandra Hospital.

5.5 Portsmouth and South East Hampshire Health Authority conducted a formal consultation period, based on the outcome of the discussions with local people in January 2000. This focused specifically on proposals to change the provision of health services for the people of Gosport and South Fareham. This clearly set out the services that would continue at RHH until the completion of developments at Queen Alexandra Hospital and the range of services to be provided on the Gosport peninsula once these developments were complete.

5.6 The Committee received a briefing note detailing the scope and outcome of this consultation in October 2003 (see Appendix One). This confirms that, in May 2000, the Health Authority gave specific commitment to a range of services being provided on the Gosport peninsula including:

· the continuation of the Haslar Accident Treatment Centre,

· inpatient rehabilitation and post acute care

· day surgery

· endoscopy services

· most outpatient clinics

· diagnostic services.

5.7 It was noted that additional physiotherapy and other therapy services would be necessary to support this provision as well as enhanced ambulance service provision.

5.8 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 RHH and the Gosport War Memorial Hospital. It was noted that this was contingent on agreement being reached with the MoD to make available part of the Haslar site for NHS use on a long term basis. The single storey `Crosslink' block was identified as being suitable for providing 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 `Crosslink' block including x-ray equipment and operating tables. Costs associated with the proposals were identified.

5.9 There was strong support from local people for the retention of the RHH as a district general hospital. This was not an option that fell within the scope of the 2000 consultation as the decision to redevelop the Queen Alexandra Hospital had already be taken with appropriate consultation.

6. Background Information 2003-Ocotber 2004

6.1 Changes to arrangements for patient and public involvement, and the scrutiny of the NHS have been rolled out with effect from January 2003.

6.2 Concerns about the future of health services in Fareham and Gosport were initially drawn to the attention of the Committee in the summer of 2003. Since this time the Committee has engaged in an on going dialogue with the health economy in south east Hampshire about the configuration of services in the area. A recurring theme in these discussions has been the future pattern of services in Fareham and Gosport. This has been reinforced by a number of actions taken specifically to inform members of the key issues and highlight areas of specific concern.

6.3 A visit to RHH in October 2003, initiated by the Save Haslar Task Force, provided an opportunity to include some County Councillors who were also members of the Health Review Committee. The range of services provided at the Hospital, in particular the diagnostic facilities that were available and the cleanliness of the facility impressed members who attended this visit.

6.4 Recognising how strongly local people felt about the retention of RHH, and taking account of the views of local councillors about the need for the RHH to remain as a resource for both the military and public, the Committee wrote to the House of Commons Health Select Committee in February 2004 (see Appendix Two) setting out its concerns about the lack of clarity regarding the future of RHH as a facility for local people, the waste of public money should an agreement fail to be reached and the potential for the MoD to close RHH before the completion of the redevelopment of Queen Alexandra. The response from the Health Select Committee acknowledged the concerns expressed but stated that there were `no immediate plans to investigate this matter'.

6.5 As County Councillors, members have consistently stated their support for the RHH to be retained as a facility providing health care to the armed forces and local people.

7. Key Issues for Consideration

The Timing and Content of Consultation

7.1 Section 11 of the Health and Social Care Act places a specific duty on the NHS to involve and consult local people about the planning of health services. Whilst there is a need for the NHS body concerned to demonstrate that it has given consideration to the views expressed, the Board of the NHS Trust concerned has final responsibility for any decision made. Factors such as clinical best practice, affordability and national policy will be taken into account as part of this process.

7.2 In addition Section 7 of the Health and Social Care Act places a duty on the NHS to formally consult the Committee on proposals to substantially change or vary health services.

7.3 The Committee will have an interest in establishing how local people have been able to contribute to shaping the proposal put forward by the PCT and what changes have resulted from the consultation. The way in which those groups that are traditionally `hard to reach' within the community will be of specific interest.

The interest of the health service in the area

7.4 The strength of feeling amongst people living on the Gosport peninsula for the retention of some NHS facilities on the Royal Haslar Hospital site must be acknowledged. The Committee therefore wrote to the PCT on 7 September asking for additional information about the development of the proposals and other factors that will inform the final decision of the Trust Board (See Appendix Three). The response of the PCT is attached at Appendix Four.

7.5 The PCT has also provided additional information on the impact on traffic in the area, the financial implications of each option and details of the consultation process. These documents have been circulated to members electronically and a hard copy is available on request. Examples of all three documents will be available at the meeting on 26 November 2004. The traffic assessment and financial option appraisal can also be found on the PCT website at www.farehamandgosportpct.nhs.uk

7.6 The extent to which the PCT is able to respond to the preferences expressed by people living in the area will be shaped by the following considerations:

1. The affordability of the options: The PCT has been clear about the financial pressures it is facing. Affordability will therefore be a key factor in assessing the viability of the options presented. The costs of purchasing and running the RHH site, which must be negotiated with the MoD, need to be clearly understood. These figures have changed considerably since the 2000 consultation, which identified the cost to the NHS in terms of estates and infrastructure at £2.2 million (source Changes to Health Services in Gosport and South Fareham, paragraph 7.9. Portsmouth and South East Hampshire Health Authority. January 2000).

The independent financial appraisal commissioned by the PCT includes costs for the purchase of the `Crosslink' building and an additional £4 million for `injurious affect'. The District Auditor supplied these figures and it is not clear if they were prepared in consultation with the MoD.

Whilst some change in cost over time is to be expected members may wish to explore the factors underpinning the difference in the 2000 costs and those presented as part of the current consultation. The letter sent to the House of Commons Health Select Committee highlighted the public funding, from both the MoD and NHS that had been invested in the RHH site. The view of the Committee was that it would be in the public interest for this resource to remain in the public sector and for all parties to work together to find a way of achieving this objective. The Committee will therefore wish to understand if the MoD supports the figures presented and the scope for the cost of the Crosslink building to be adjusted to reflect the considerable public funding that has been invested in the RHH site.

2. The Health Needs of the Population: The responsibility of the PCT to commission services that meet the health needs of local people now and in the future. The commitment of the Health Authority in 2000 was to Gosport and south Fareham. It is not clear how the needs of the population from other parts of the Borough of Fareham would be met. This point is particularly important in relation to the configuration of community and primary care services across Fareham and Gosport and the facilities provided, or planned in the two community hospitals. The Committee has repeatedly asked for information on the health needs of local people that moves beyond and analysis of activity (see Appendix Three). This has included a request for information impact of the options presented on vulnerable groups living in the area served by the Committee (Appendix Three point 1). This information has not been made available and members may wish to explore further how these considerations have contributed to the identification of the preferred option.

The NHS Modernisation Agency defines health needs assessment as follows:

`In order to be able to commission health services on behalf of local people the PCT needs to have a clear understanding of the current and future health needs of the population that is serves.

Health needs assessment is defined in the literature as a long term forecast, looking ten years ahead, at the health needs of the communities served by a PCT to help determine - and justify - commissioning objectives

It should be informed by a health equity audit. This is a mechanism for using evidence about health inequalities to inform service planning and delivery. Data collected during health needs assessment feeds into the health equity audit cycle, which is a mechanism for reducing inequalities in health by producing an equity profile, agreeing local priorities and actions, securing change and reviewing progress.

Needs Assessment is a multi disciplinary task that requires inputs from public health specialists, primary care clinicians, information specialists, finance professional and general managers.

It should be developed with full contributions from the community, the voluntary sector and the relevant local authority(s) responsible for the social and economic well-being.

It may be beneficial to develop the assessment in partnership with other PCTs in the health system.

Local NHS Trusts should be included in the process of assessment, particularly in the assumptions about medical technologies and future treatment rates. It should be developed in conjunction with the assessment and should take into account:

· Demographic change including changes in the age profile and the social deprivation and economic well being of the community.

· Changes in morbidity, for example increases in the incidence of particular clinical conditions e.g. asthma, obesity.

· Health inequalities, by identifying differential needs of different areas and groups, differential rates of access and health outcomes, preferably by considering these across the care pathway

· Changes in medical technology, including new drugs. It is important to identify technology changes that are likely to make treatment accessible to a greater proportion of the community. For example in the last decade improvements in anaesthetics and intensive care are enabling frailer patients to have major orthopaedic interventions. The long term benefits of current improvements - for example in primary and secondary prevention in Coronary Heart Disease - are difficult to forecast but do need to be taken into account.

· Local access rates (per `000 weighted population) and disease prevalence rates trends should be compared with other PCTs and national averages and that should inform forecasts of future needs. Decisions to plan the provision of services above or below anticipated averages should be explicit and justified. It is important to recognise how far changes in thresholds for interventions can affect future capacity.

· Possible reductions in care needs should also be forecast, for example a falling birth rate will reduce the future volume of obstetric care required.' (Source: NHS Modernisation Agency: National Primary & Care Trust Development Programme: Key Steps in Commissioning)

3. 2000 commitments to Local People: Following the announcement of the Ministry of Defence to close RHH in 1999 a comprehensive consultation exercise was undertaken and specific commitments were made to people living in Gosport and south east Fareham. These are described in more detail above and at Appendix One. The PCT has stated its intention to honour these commitments.

Any variation to these commitments will need to demonstrate the engagement and involvement of patients and the public (Section 11, Health and Social Care Act) and, where the change is substantial, formal consultation with the Committee (section 7 of the Health and Social Care Act).

Members may wish to explore the extent to which the commitments made in 2000 will be delivered in the preferred option identified by the PCT. A particular area for consideration in this respect is the provision of care outside core working hours.

4. The Redevelopment of Queen Alexandra Hospital: The consultation process undertaken in 2000 confirmed the redevelopment of Queen Alexandra Hospital would take place and that, on completion of this work inpatient services for south east Hampshire would be located on this site. This issue has been subject to previous formal consultation and it is not the intention of the Committee to revisit the decisions made in 2000.

The arrangements for provision of inpatient care prior to the completion of the Queen Alexandra redevelopment is a matter of interest to the Committee, in particular the contingencies put in place to ensure that local people have access to the in-patient care they need.

There have been delays of nearly a year in securing financial close on the Private Finance Initiative (PFI) to redevelop Queen Alexandra Hospital. Estimates are that this work will not be completed until summer 2008. RHH has continued to provide a significant amount of inpatient care in this period. Should the MoD determine that RHH should close in the spring of 2007 there needs to be clarity about how these in-patient services will be provided. The management of any transition process required therefore needs to be fully understood by members and clear to local people. Contingency arrangements will need to be in place to ensure that local people are able to access the inpatient care they require in this period.

5. Out of Hours (OOH) and Unscheduled Care: The Committee has consistently stated its support for there to be an integrated approach to the provision of OOH and other unscheduled care. This reflects the findings of the recent House of Commons Health Select Committee investigation into the changes to OOH provision as a result of the implementation of the new GP contract. A briefing paper on this matter went to the meeting of the Committee on 21 September 2004.

In the letter from the Committee to the PCT (see Appendix Three, point 4) seeks information about the scope for developing an integrated model of unscheduled care across Fareham and Gosport, using the facilities provided by the community hospitals in Fareham and Gosport as fully to complement existing A&E provision and ambulance services.

Although the response from the PCT (see Appendix Four) indicates that this issue is being considered no specific information is available on how this work will be rolled forward, or the timescales within which this will take place. Members may wish to test this point further in discussions with the PCT.

Recommendations

That:-

a. The Committee considers the proposal from Fareham and Gosport PCT, taking

account of the views of key stakeholders and any supporting evidence provided

b. The Committee provides feedback to the PCT on the proposals taking account

of whether the Committee is satisfied

· With the content of the consultation and that sufficient time has been allowed.

· That the preferred way forward identified by the PCT is in the interests of the health service in the area affected.

c. An up-date on the response of the PCT to any recommendations is

received at the next meeting of the Committee and any further action decided

at that time.

Section 100 D - Local Government Act 1972 - Background Documents

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 of confidential information as defined in the Act.

None

Appendix One

Briefing Note: Redevelopment of Queen Alexandra Hospital and reconfiguration of health services in South East Hampshire: October 2003

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 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 workload.

· 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 Crosslink block including x-ray equipment and operating tables. Costings 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.

Appendix Two

Dear Mr Hinchcliffe

Future of Royal Naval Hospital Haslar, Gosport

I am writing to ask if you are able to take any action in relation to discussions between the Ministry of Defence (MOD) and the Department of Health regarding the future of the Royal Naval Hospital Haslar. The MOD has recently reaffirmed its intention to move from the Haslar site in 2007. Without agreement regarding the transfer of the Hospital and its services to the NHS this will mean the loss of an excellent facility for both local people and the armed forces. It is difficult to see how such an action would be in the interests of either the public, the NHS or the MOD.

You may recall that there has been extensive public support for the retention of Haslar Hospital as a resource for local people. This resulted in the matter being raised in the House of Commons; the last adjournment debate took place in October 2002, initiated by the Gosport MP Mr Peter Viggers.

The Haslar site is owned by the Ministry of Defence and the Hospital is a listed building. The MOD first indicated its intention to withdraw from the site in 1998 prompting a massive public outcry. The Portsmouth and South East Hampshire Health Authority undertook a full public consultation exercise at that time to determine the health services required on the Gosport peninsula. The outcome of this process identified Haslar as the preferred site for providing the NHS services needed by the local population. This was subject to agreement with the MOD regarding the transfer of part of the site to the NHS. Despite repeated attempts by the local PCT and Hampshire and the Isle of Wight Strategic Health Authority to secure this transfer, no agreement has been reached. Incredibly, the MOD announced in the press recently that it intends to raise the charges to the NHS for the use of Haslar from £1.3 million to £9million per annum, an increase of over 700%!

Plans are progressing for the redevelopment of the Queen Alexandra Hospital Cosham, via a PFI programme. This is intended to provide acute medical care, major trauma and other specialist services.

The anticipated completion of the PFI contract has however already incurred slippage due to planning difficulties. There is a very real concern that, should the MOD persist with its plans, Haslar may shut before the new acute hospital is completed. This would be catastrophic for local people.

In addition both Gosport and Fareham Borough Councils have highlighted concerns that the basis on which the original planning assumptions were predicated does not take account of new housing developments in the area or other demographic changes. These will inevitably result in new demands for health services in this area, which a facility such as Haslar Hospital would be well placed to meet.

Haslar Hospital currently provides a wide range of services including elective surgery, out-patient clinics, diagnostics, an accident treatment centre and recently opened orthopaedic treatment centre. Investment in the Hospital by both the NHS and the military has been significant and resulted in a `state of the art' facility providing an enviable quality of equipment and service. Whilst the redeveloped Queen Alexandra Hospital will provide much of the acute care for local people in the future the scope for Haslar to provide intermediate and elective care is considerable, particularly as technology extends the range of procedures that can safely be provided in this way.

Having visited the site there is no doubt that it is an excellent asset for local people. Patients, health professionals, local government and the public have indicated their support for the retention of the Hospital in the strongest possible terms. Fareham and Gosport PCT is currently working with local people and organisations to review the health needs of the population and clarify options for delivering the full range of services promised to people living on the Gosport peninsula. The lack of agreement on the transfer of the site to the NHS and the recent action by the MOD to significantly increase the charge it makes to the NHS is effectively removing Haslar Hospital from this discussion. We do not consider this to be in the interests of the local health community or an appropriate use of public finance.

It seems incomprehensible that this Hospital, funded from the public purse to such an excellent level of provision, is to be lost to the population of Southeast Hampshire. Given the other changes that are happening to health services in this area we believe this matter needs to be dealt with speedily. There is a genuine commitment from all interested parties locally to resolve this problem in a way that will bring benefits for all concerned. I am therefore writing on behalf of Hampshire County Council Health Review Committee to ask if you are able to provide any support in securing the future of the Royal Naval Hospital Haslar to the best local and financial effect.

Cllr Dr Raymond J Ellis C.Chem FRSC

Chairman, Hampshire County Council Health Review Committee

Cc Cllr M Snaith

Cllr K Thornber

Mr P Viggers, MP

Cllr B Bayford

Cllr D Wright

Mr G Cruddace

Mr I Piper

Mrs L Doherty

Appendix Three

Dear Ian

The Future of local health services in Fareham and Gosport

I am writing on behalf of the Health Review Committee to ask for some additional information in relation to the consultation document issued by the PCT in late July.

The debate about the future of services in Fareham and Gosport has been of intense public interest for some considerable time. Many of the issues raised by local people have stemmed from concern that a highly regarded local health facility, the Royal Hospital Haslar, will be removed from public service in 2007. Although the decision to close the Hospital has been made by the Ministry of Defence, many people living on the Gosport peninsula have indicated their support for the continuance of NHS services on the site to make best use of the public monies that have been invested in the facilities. You are aware of the views of the Committee on this matter and the comments we have made to the House of Commons Health Select Committee. We remain of the view that the decision of the Ministry of Defence to close the site is deeply flawed, driven by short term budgetary pressures rather than the interests of our armed forces and people living on the Gosport peninsula. The work the PCT has undertaken to assess the potential to continue to provide NHS services on the Haslar site is appreciated and we look forward to receiving details of the independent review of the financial implications of this option.

The Committee, in line with its statutory responsibilities, will be considering the consultation process and preferred way forward identified by the PCT at a special meeting on the 21 October, in the meantime there are a number of points on which we would request additional information prior to this meeting.

Further information of the health needs of the different communities living in Fareham and Gosport and how these have shaped the current proposals that are subject to consultation would be particularly helpful to the Committee at this juncture. The consultation document is clear about the preferences of local people in relation to the provision of health services in their area. These preferences will however need to be balanced against a clear understanding of the current and future health needs of the population served by the PCT.

Although it was useful to see a copy of the analysis of activity across NHS services used by people living in the Fareham and Gosport area this only gives an overarching picture of how the population will change and grow in the next few years (i.e. by 4.5% in Fareham and 7.9% in Gosport). It is not clear how this information has been used to build a clear understanding of the health needs of the different communities that comprise the population served by the PCT and shape the current proposals for services in Fareham and Gosport. As I recall this point was raised at a recent meeting that you had with Portsmouth City Council and the intention at that time was to commission a further assessment of the changing health needs of the population.

Considerations such as an aging population, birth rates and deprivation will all influence the pattern of health services that local people need. Other factors such as transport (which has specific relevance for people travelling to and from Gosport and living on the peninsula), advances in technology and changes in primary care services will in turn impact on what can be provided locally to meet these needs. Both Fareham and Gosport Borough Councils have consistently stated that changes in the local population, such as new housing developments, have not been fully considered in the pattern of health services that is being suggested across south east Hampshire. In the context of the current consultation this issue has now reached the point where different populations in the Fareham and Gosport area are concerned that they may be disadvantaged, or have access to services compromised, by a decision to site a particular service in another part of the patch. The current debate over the range of services to be provided at the Coldeast Community Hospital is a specific example of this point. We consider this to be divisive and unhelpful. It is essential that there is clarity regarding the health needs of people living in both Fareham and Gosport and how the options presented in the consultation document will be able to meet these needs.

Additionally the Committee is mindful that the NHS has made very specific commitments to people living on the Gosport peninsula in terms of the health services that would be provided. People living outside this area must be confident that these commitments will not compromise the delivery of health services able to meet their needs in the future.

Following on from this point there are a number of more specific issues that we would appreciate your comments on:

1. Page 13 of your analysis of activity provides a profile of deprivation in local authority wards within Fareham and Gosport. What assessment has been made of the impact of the options currently subject to consultation on these populations?

2. Page 11 of your consultation document is clear that the Queen Alexandra Hospital will take on acute inpatient work once it is redeveloped. In the meantime the treatment centre at the Royal Hospital Haslar is actively contributing to reducing waiting times for elective orthopaedic patients. Our understanding is that demands for acute trauma services are continuing to build. Given this point, has any modelling been done to test the scope for the continuation of a separate elective orthopaedic treatment centre for people in south east Hampshire? This could further reduce waiting times and absorb elective capacity displaced by pressures on emergency trauma services at the new Queen Alexandra Hospital. In other areas of Hampshire the case for the separation of elective/routine care from emergency and specialist care is being actively explored and we would be interested to know if the options for a similar pattern of services in south east Hampshire have been considered

3. We strongly support the development of community hospital services in both Fareham and Gosport. It would be helpful to have confirmation that, in its role as commissioner of services on behalf of local people, the PCT will ensure that there in sufficient capacity in the facilities provided to deliver an increasing amount of care either in the community hospital or primary care setting, in line with `Improving Local Services' and able to meet the growing needs of both populations. We would be particularly keen to see community hospital provision which has the level of flexibility that the new Lymington Hospital will include.

4. The use of community hospitals and the contribution that they make to out-of-hours provision was highlighted in the recent House of Commons Health Select Committee Report. Noting the comments in your consultation document on the use of the accident treatment centre at Haslar Hospital we were not clear what work had taken place to explore the scope for linking this service with other out of hours and emergency services across the area. This would secure a new integrated service model able to provide 24 hour cover to people living in Fareham and Gosport and fully utilise these hospitals as facilities at the heart of each community. Two thirds of primary care is now provided out of hours and pressures on general practitioners and other staff require that new ways of working be explored. Minor injury units, walk-in centres and accident treatment centres are different in the level of service they provide and each has a contribution to make to the development of integrated `unscheduled care services' in both Fareham and Gosport. These would complement each other and support ambulance services and A&E. There is no indication in your document that the options associated with these developments have been explored.

5. The HealthFit document consulted on by the Strategic Health Authority earlier this year suggests that intermediate care facilities will be developed in south east Hampshire `centred on community hospitals and primary care facilities'. It would be helpful to have further detail of exactly the form that this will take for people living in the Fareham area.

6. Remaining with the theme of community hospitals and HealthFit, the SHA document refers to children's services and the establishment of `treatment and transfer protocols, and video consultation with minor injury units and `small' hospitals'. Could you confirm how you envisage these services being provided within the options included in the consultation document?

7. We would be interested to learn if the PCT anticipates that there will be scope for further extending the number of out patient clinics in the area beyond 30% to minimise travel for local people

8. With regard to the reference to continuing care beds the consultation document makes reference to 80 new nursing home beds for local people. This is different from continuing care and it would be helpful if you could confirm what provision is being made to the way in which the 27 in patient beds at St Christopher's will be re-provided to ensure that there is appropriate provision for older people requiring both continuing care and assessment now and in the future. An indication of how this work is being progressed in partnership with social services would also be appreciated.

A final, slightly broader point on which we would appreciate your comments relates to the arrangements that will be put in place to manage any delays in the completion of redevelopment of Queen Alexandra Hospital. This was originally intended to be signed off in January this year. I understand that the contract has yet to be finalised with the Hospital Company. If this results in a delay to the completion of the redevelopment there is a significant risk that the Ministry of Defence will close the Royal Hospital Haslar without the new provision being available for local people. This point has been raised repeatedly in meetings and other discussions about the future of services in the area and I think we have now reached the stage where we need an assurance that contingency plans will be put in place to ensure that local people have access to the health services that they need.

Yours sincerely

Cllr Dr Raymond J Ellis C.Chem FRSC

Chairman, Health Review Committee

Appendix Four

Cllr Dr RJ Ellis C.Chem FRSC

Chairman,

Health Review Committee

Hampshire County Council

Members Room

The Castle

Winchester

SO23 8UJ

12 October 2004

Dear Councillor Ellis

I write with reference to your letter dated 7^th September 2004 to Ian Piper, which has been passed to me for a response.

With regard to the likely impact of the proposals on the populations of Fareham and Gosport I enclose the pack of health needs information that was presented to the public during the four consultation meetings on 27^th September and 4^th October. Kathryn Rowles, Director of Public Health will attend the meeting to talk to the documents.

Capacity modelling for both elective and emergency orthopaedic services has been undertaken in conjunction with Portsmouth Hospitals NHS Trust (PHT). Based on this modelling, the PCT and PHT have developed a capacity plan for the next three years which sets out the level of activity to be commissioned from PHT in order to ensure the delivery of the maximum waiting times targets. PHT will have the capacity to undertake this activity and the PCTs will also continue to commission services from a range of local providers to ensure patients have plurality of choice.

This will include new treatment centres at both Southampton and Winchester.

The PFI will ensure the delivery of elective and emergency activity on a single acute site, ensuring the most effective use of resources. The PCT supports the development of the PFI and the continued commissioning of elective orthopaedic services from PHT as its main local acute provider.

The PCT has included some spare capacity in both proposals in order to expand services in future. We can confirm that Fareham Community Hospital will learn the lessons from the new Lymington Hospital in terms of flexibility for the future. This is particularly important given the population growth forecasts for the western wards.

The demand profile for the Out of Hours Service and emergency care is being looked at to ensure that there is capacity and whether it is in the right place, before it can all be linked together.

The existing Out of Hours service is a replacement service structured around that previously provided by the GPs to ensure continuity and that the PCT fulfils its statutory obligations. Work is ongoing with all of our partner organisations such as the Hampshire Ambulance Service and NHS Direct to look at future service provision, skill mix and access to primary care.

Primary care actually takes place in the surgery and emergency/unscheduled care takes place outside of practice hours. Many of the developments within primary care have led to better use of resources thus making practices more efficient during their opening hours. There will be further developments over the next two years within primary care as we start to apply a skill mix of GPs, nurses and other healthcare professionals. These are the clinical and medical developments that need to take place but these should be done in conjunction with service redesign of social and voluntary services to ensure that we make best use of all our estates, facilities and IM&T infrastructures.

The PCT and PHT will be consulting on services at night with Fareham and Gosport residents early in the New Year.

With regard to your reference to the HealthFit document I enclose a copy of our Intermediate Care Strategy as requested.

On the subject of treatment and transfer protocols, and video consultation/links, we have discussed this with PHT and they will be responding separately.

Referring to outpatient clinics, the PCT believes that there will be scope for increasing outpatient clinics beyond 30% in order to minimise travel for local people. The figure of 30% was calculated on the basis that plain film x-ray and ultrasound would be available at Community Hospitals and it will be. As technology progresses and other diagnostic facilities become more portable and affordable, there is potential for an increase from 30%. The PCT and PHT will work closely on developing these facilities in future.

The 80 continuing care beds at Coldeast are a joint development between health and social services. They are nursing home beds and will inevitably provide a level of care to people with some `NHS continuing care' needs as well as to others who have ongoing nursing needs.

The 27 beds at St Christopher's are being reprovided due to the unsuitability of the environment. This issue was flagged up as urgent following an unfavourable Patient Environment Action Team (PEAT) report. The PCT assessed the needs of the current patients and alternative services have been commissioned to meet those needs. This had led to patients being placed in local nursing homes. Patients requiring assessment and treatment will be treated in hospital, either acute or community depending on their needs. In addition, services are being developed that will increasingly treat people in their own homes if that is their preference. All of this work is being progressed in partnership with Social Services colleagues and other local stakeholders including patients and their carers.

Finally, discussions are ongoing between Portsmouth Hospitals Trust and the Ministry of Defence about the continued use of the Haslar site from 31^st March 2007 until the redevelopment of QAH is complete in Summer 2008. Portsmouth Hospitals Trust and the Primary Care Trust will work together to ensure that we continue to provide services to our patients during that period.

Yours sincerely

Inger Hebden

Director of Strategic Development