Contact: Denise Holden ext. 7338

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1. Summary and Purpose

1.1. This report provides Members with information about the issues brought to the attention of the Committee and the response to these referrals. It sets out the inquiries received, the source of this inquiry and any action taken. 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 (P&PIFs) and other partner organisations (Hampshire district councils, NHS organisations, 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. New issues raised with the Committee, and those that are subject to on-going reporting are set out in Table One of this report.

1.6. 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.

Table One: Inquiries Received and Action Taken

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.

Appendix One

A REVIEW OF THE OESOPHAGO-GASTRIC SERVICES IN THE

SWSH CANCER NETWORK

MAY 2006

INTERIM REPORT

INTRODUCTON:

This review was commissioned by the Network following an approach made to Professor Mike Richards, National Cancer Director, by the CEO of the Surrey and Sussex SHA in late January 2006. The letter requested an external review to provide the following:-

"Confirmation that the plan and strategy that we have adopted with SWSH is in line with the NICE IOG and provides the most sensible solution to meeting those requirements."

"Confirmation that the issues raised in the recent Peer Review Report are being addressed by the management and clinical teams at the Royal Surrey Count Hospital which will enable the smooth transfer of services in line with the agreed timetable."

I was invited by the Chairman of the SWSH Cancer Network to undertake this review.

PRIOR TO THE VISIT:

I was provided with background information and a briefing paper by the Network Director covering progress made since the first round of Upper GI Peer Review in February 2004. I received a copy of the "Strategic outline business case for the development and centralisation of oesophagogastric cancer services" dated June 2005.

I requested from the two Trusts, Frimley Park NHS Foundation Trust (FP) and The Royal Surrey County Hospital NHS Trust (RSC), detailed information about their oesophago gastric (OG) surgical services over the past three years including the total number of cases, the number of resections, mortality and morbidity data and copies of their Operational Policy. Detailed information was received from FP but the information received from RSC covered only two years and was scanty and incomplete.

THE VISIT:

On Wednesday 3^rd May 2006 I made a half day visit to each Trust where I viewed Critical Care, Theatres, Endoscopy and Radiology facilities and held meetings with the clinical teams, CEO and patient representatives. I met for one hour with the Chair of the Tumour Working Group and the Director of Public Health and Medical Director of Guildford and Waverley PCT, and at the end of the day held a meeting with representatives of the Network and the SHA. I was escorted throughout the day by the Network Director who was present at all my meetings.

THE PROBLEM:

Facilities and expertise exist within the Network to provide an outstanding modern, innovative and safe service. The IOG requires this to be delivered on a single site, and in June 2004 the Network chose RSC as the preferred site, the move to be achieved by October 2006. The current stand off between the two major providers of OG surgery has arisen because the choice of site has become contentious. FP has challenged the Network's choice and this challenge is based on a number of issues. These include the method of site selection, the failure to reach clinical agreement, the need to develop the RSC site, the cost involved and the consequent need to move or disband the FP service which is currently the larger and better established of the two services and has recently been Peer Reviewed as an exemplar service.

The clinical and managerial positions have become polarised and this is compounded by recent public involvement.

ACHIEVING A SOLUTION:

The final decision as to which site should be developed for OG cancer surgery rests with the Network Policy Board (NPB). The NPB has chosen the RSC site but in so doing has a responsibility to its population to ensure that the service provided there will be as good as, if not better than, that currently provided at FP. On current evidence and the stage of development of the RSC services, that assurance cannot be given within the current timetable.

A solution will only be achieved if both parties:-

· Accept that the current situation cannot continue and that one site has to be agreed and developed.

· Recognise that the clinical strengths, facilities and infrastructure which exist across the sites within the Network must be fully utilized to provide the best possible Network service.

· Accept a process for resolution that acknowledges the concerns of both parties and works towards a solution that is fair, open and assessable and provides an OG service that is innovative, sustainable and safe.

Before a process can be recommended two questions need to be answered:-

· Should the timescale to move to a single site by October 2006 remain?

· Is RSC the better site for the OG centre in the long term?

In my view the answer to the first question is NO and the second question YES.

The timescale should not be considered fixed and the NPB should agree a revised date of October 2008 for all OG cancer surgical services to be on one site.

An OG cancer centre will need to provide all surgical modalities of care and should encompass standard open surgery as well as minimally invasive techniques. The RSC has expertise in minimally invasive oesophagectomy (MIO) and has the facilities to develop this further through the MATTU and in addition has a state of the art minimal access theatre. The Network strategy is to develop RSC as the Cancer Centre siting all specialist cancer surgery on the site. However, this site would only be appropriate if the investment in the infrastructure as outlined in the Business Case were carried out by October 2006 and the newly enlarged service could demonstrate that its outcomes and quality of care were as good as if not better than FP. To achieve this would require the two surgical teams to work in parallel for a period of assessment and therefore cannot be achieved within the current timescale..

The management at RSC gave an undertaking that despite the present financial position they are committed to the necessary investment. To this end an additional consultant surgeon has been appointed and the remaining appointments will be made by October 2006. At that date both teams will be of comparable size, each with two surgeons committed to OG cancer surgery and no further consultant surgical appointments should be made as the Network establishment is now large enough to provide an appropriately staffed service on the site that is finally chosen. The two surgical teams should work as a Network wide Specialist MDT providing surgery on two sites, and between October 2006 and October 2007 the two surgical teams should provide a detailed audit of their work suitable for external evaluation. If by October 2007 the new RSC team has demonstrated the necessary investment and a comparably safe service all surgery should move to RSC during 2008 with the development of the necessary contractual arrangements to allow the full use of all the existing network wide expertise. If, however, the RSC fails to fulfil the above criteria the service should move to and be further developed at FP.

RECOMMENDED ACTION TO BE TAKEN BETWEEN JUNE 2006 AND OCTOBER 2008:

A single Specialist MDT.

The Network should immediately establish a single network wide Specialist MDT at which all cases diagnosed and treated within the Network are discussed. It should have a single clinical lead and its core membership should incorporate the MDTs at RSC and FP. It should meet weekly and preferably in person, alternating the meetings between the two sites. If this is not possible meetings should be by video link. It should work to a single agreed Operational Policy covering the diagnostic, investigative and treatment pathway.

Two site surgery.

All oesophago gastric resections for cure should cease at St. Peter's Chertsey and Redhill, the oesophageal and gastric cases from Chertsey should be referred to RSC and the gastric cases from Redhill to FP. This should start as soon as the newly appointed surgeon at RSC is in post and at the latest by October 2006.

Data collection.

The Specialist MDT should agree a minimum data set at least as comprehensive as that currently collected at FP. The Specialist MDT should meet quarterly to agree the data and present it quarterly to the TWG. This should start immediately and must be in place by October 2006. This is crucial for RSC as the data presented for this review was scanty and incomplete.

External Audit

The collected data is unlikely to be suitable for statistical analysis due to the relatively small numbers. When the third quarter data for the year October 2006 - October 2007 is available the NPB should consider inviting a senior member of the Association of Upper Gastro Intestinal Surgeons (AUGIS) with an OG interest to undertake an external review of the data.

Final decision.

After consideration of the report of the external auditor and an assessment of the investment made in the infrastructure at RSC, the NPB should make a final decision as to the site for the future development of the OG cancer surgical service. The move to the chosen site should be completed by October 2008

Implementation.

All parties should accept the NPB's final decision and the Network and the SHA must support the two Trusts in implementing the decision. The Trusts may need support in the form of additional investment to allow the readjustment of timetables and the movement of contracts which may be necessary to allow all the surgical, anaesthetic, radiological and nursing expertise currently available in the Network to be available on the single site.

It would be the responsibility of the NPB through the Upper GI Tumour Working Group to monitor the above actions.

CONCLUSION:

In the light of the concerns that have been raised both within the Network and publicly over the choice of the site, and the need for the NPB to fulfil its governance responsibilities, it is recommended that the surgical teams at FP and RSC work in parallel as part of a Specialist MDT for a period of assessment. Following detailed analysis of the outcomes and services provided by the two teams the NPB should make its final decision in October 2007. All parties` should accept that decision and work together to use the expertise that already exists in the Network to create an outstanding and sustainable OG service.

ADDENDUM

During the review it was brought to my attention that a surgeon in Worthing who is currently carrying out MIO wished to move his work to RSC. If this surgeon takes up sessions at RSC and his cohort of patients are treated at RSC they will form part of the RSC service to be assessed. All the patients must be discussed in the Network Specialist MDT and all the surgeons undertaking MIO, both those with their contracts at RSC and any "in reach" surgeons, must work to the "Augis Statement on Laparoscopic Upper GI Cancer Surgery" endorsed by Professor Richards in October 2005. Evidence of compliance with this would form part of the external audit recommended in this review.

John Bolton MSc FRCS