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Hampshire County Council Health Overview and Scrutiny Committee Item 5 27 November 2007 Proposals to Develop or Vary NHS Services Report of the Chief Executive |
Contact: Denise Holden ex 7338
e-mail: [email protected]
1. Summary and Purpose
1.1. The purpose of this report is to alert Members to proposals from the NHS to vary or develop health services provided to people living in the area of the Committee.
1.2. Proposals that are considered to be substantial in nature will be subject to formal public consultation. The nature and scope of this consultation should be discussed with the Committee at the earliest opportunity.
1.3. The response of the Committee will take account of the Framework for Assessing Substantial Change and Variation in Health Services agreed by the Hampshire, Isle of Wight, Portsmouth and Southampton Joint Committee in March 2005. This places particular emphasis on the duties imposed on the NHS by Section 11 of the Health and Social Care Act 2001.
1.4. This Report is presented to the Committee in 2 parts:
_ Items for information: these alert the Committee to forthcoming proposals from the NHS to vary or change services. This provides the Committee with an opportunity to determine if the proposal would be considered substantial and assess the need to establish formal joint arrangements
_ Items for action: these set out the actions required by the Committee to respond to proposals from the NHS to substantially change or vary NHS services.
1.5. This report and recommendations provide members with an opportunity to influence and improve the delivery of health services in Hampshire and therefore
support the delivery of the Corporate Strategy aim of maximising well being.
Items for Information
2. Review of Maternity Services in South West Hampshire
2.1. Following a press release from SUHT stating that, due to a delay in the rehabilitation services moving from the Ashurst site the opening of the new centre will be delayed until the autumn, the HOSC has been pressing for a date when the new facility would be open.
2.2. When this was not forthcoming the Chairman requested the following information from the Trust:
· a formal report to go to the Committee outlining the causes of the delay and why it was not possible to anticipate this problem
· what is being done to remedy this and the time line to opening the new facility.
· what steps have been taken to inform local women and staff about the delays and ensure that information is being provided to allow them to exercise choice.
2.3 In particular the Chairman highlighted that members would be interested in what actions the Trust is taking in those areas that have already lost their birth centres. Local families expressed considerable concern about the loss of facilities and it is essential that they have confidence that the new centre will be open as soon as possible.
2.4 In response the Trust has now said that the new facility will not be open until June 2008. The Chairman reiterated his wish for the information outlined above to be provided to the HOSC and asked that a senior members of the Trust Management team attends the meeting on 27 November to answer any additional questions members may have.
Recommendation
2.3. Members have clear information about the timeline to the opening of the birth centre at Ashurst and that the way in which this has been communicated to local people.
2.4. SUHT provides the HOSC with regular up-dates on progress with the development of the Ashurst site
3. NHS Review: Joint Response from the Executive Lead for Adult Services and the Chairman of the HOSC
3.1. Following the invitation to comment to the Darzi Review of the NHS the Executive member for Adult Services and HOSC Chairman agreed the response attached at Appendix One. This builds on the findings of the Committee, particularly with regard to Care at the End Life.
3.2. The SHA is leading the wider consultation on the Darzi Review, scheduled to report in the summer.
Recommendation
3.3. That the Committee notes the initial response to Lord Darzi.
4. Specialist Palliative Care Services in South East Hampshire
4.1. Hampshire PCT has alerted the HOSC to formal notification from Portsmouth PCT of its intention to withdraw from existing arrangements for commissioning specialist palliative care services in south east Hampshire.
4.2. It is not yet known how this action will affect the existing team or the range of services offered.
Recommendations
4.3. That the PCT provides the HOSC with full details of the anticipated impact of the proposals on services delivered to the residents of southeast Hampshire.
4.4. That Hampshire HOSC, if appropriate in discussion with Portsmouth HOSC, comes to a view on whether these changes are substantial.
5. Surrey and Borders Partnership NHS Trust: Improving Adult Mental Health Day Services
5.1. Surrey and Borders NHS Trust has alerted the HOSC to a consultation on these services.
5.2. Hampshire Adult Services have confirmed that it is not anticipated that these changes will have an impact on people in Hampshire.
5.3. Surrey HOSC, Rushmoor Borough Council and Hart District Council have been made aware of the proposals.
Recommendation
5.4. As the changes will not affect Hampshire residents no response is required from the HOSC.
Items for Action
6. West Sussex PCT: Acute Service Reconfiguration
6.1. Hampshire and Portsmouth HOSCs have now completed the working they were leading on A&E services as part of the formal select committee process. The report on these services is attached at Appendix Two.
6.2. HCC has responded to the JHOSC, setting the issues from a Hampshire perspective. This is attached at Appendix Three.
6.3. As the formal consultation conducted by the PCT will cease in mid November, Hampshire and Portsmouth members of the JHOSC have asked the Chairman to convey a number of concerns to the PCT. These are attached at Appendix Four.
6.4. No further response has been provided by the Independent Reconfiguration Panel following the referral from the JHOSC.
6.5. As at the 31 October the PCT had received 38 alternative options.
6.6. The most recent up-date from West Sussex PCT and consultation document is available at http://www.southeastcoastfff.nhs.uk/Home/West-Sussex.aspx . Hard copies of the proposal were received in the scrutiny office on 18 August and were tabled at the meeting on 25 September.
6.7. Hampshire District Authorities, MPs and P&PIF have been kept apprised of the Hampshire HOSC's involvement and views.
Recommendation
6.8. Members are kept apprised of the progress of the Joint West Sussex HOSC.
7. Maternity Services in South East Hampshire
7.1. The response from the HOSC to the consultation is attached at Appendix Five. This sets out the views of the Committee about the consultation process and the options presented.
7.2. The PCT analysis of the responses to consultation, and the preferred option to be presented to the PCT Board, is attached at Appendix Six.
Recommendation
7.3. Members are satisfied with the preferred option identified by the PCT.
8. Surrey PCT- Fit for the Future- Commissioning Intentions
8.1. Surrey HOSC has confirmed to Surrey PCT that, with the exception of renal services it does not consider that the changes put forward are substantial in nature.
8.2. Hampshire will be less affected by the changes than Surrey so it is unlikely that the impact on local service delivery will be significant. In taking this work forward however the HOSC has already indicated that it will expect Surrey PCT to:
_ Continue to engage with local stakeholders to shape and inform the commissioning intentions, including district councils
_ Engage with Hampshire PCT, Adult Services and Children's services as the process rolls forward to ensure that any changes that affect service delivery in Hampshire can be taken into account.
_ Undertake further work with GPs and community service providers across the area affected and ensure that appropriate staffing and infrastructure is in place across community and primary care to deliver the changes envisaged.
_ The need to engage with a range of local stakeholders, including district Councils was recognised
Recommendations
8.3. Members agree with the view of Surrey HOSC that , with the exception of Renal Services, the changes proposed do not at this point in time constitute a substantial change in service delivery.
8.4. Members identify any additional issues to be raised with Surrey PCT.
8.5. The HOSC receives details of the proposals to vary renal services in order to come to a view on whether the changes will be of a substantial nature for Hampshire residents.
9. Links Regulations: draft response to consultation
9.1. The Department of Health launched its consultation on the draft regulatory framework for LINks on 28 September- this will close on the 21 December. The framework has previously been electronically circulated to members.
9.2. To enable LINks to carry out their role, the legislation gives the Secretary of State a power to make regulations imposing duties on commissioners and certain providers of health and social care services to respond to LINks (to requests for information and to reports and recommendations made to them by a LINk) and to allow entry by LINks to premises under certain conditions.
9.3. A draft response to the consultation is attached at Appendix Seven
Recommendation
9.4. Members agree the draft response to the Department of Health
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
FH/tf |
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Councillor Felicity Hindson | |
9 October 2007 |
Executive Member for Adult Social Care |
Prof. the Lord Darzi of Denham FREng, KBE, FMedSci Parliamentary Under Secretary of State, Department of Health Richmond House 79 Whitehall London SW1A 2NS |
Trafalgar House, The Castle, Winchester |
Hampshire SO23 8UQ | |
Telephone 01962 847200 | |
Fax 01962 847159 | |
E-mail [email protected] | |
www.hants.gov.uk | |
Dear Professor Darzi
Hampshire County Council welcomes the opportunity to contribute to your wide-ranging Review of the NHS. Our response includes feedback from our Health Overview and Scrutiny Committee (HOSC).
Our Adult Services Department is heavily involved in supporting people who access NHS services either in an emergency or on a long term basis. From our experience of working very closely with this group, there are a number of factors which it would be helpful for the second stage of your Review to consider if it is genuinely going to make a difference to quality of life for these often extremely vulnerable and dependent people. These points have been emphasised by a recent review of `Care at the End of Life', undertaken by our HOSC which highlighted
· The need for there to be opportunities to bring together funding streams for health and social care to secure greatest effect for patients and their families
· The fragmentation of key policy initiatives across different government departments (e.g. services for older people)
· Variable support in services provided in a community setting, particularly out of hours impacting on the ability of service providers to treat people in their own homes or other local settings
In general terms, we believe this Review provides an opportunity to recognise and emphasise the impact of demographics and consequential changes in morbidity and mortality on our ability to provide health and social care services. It is difficult to see how improvements can be achieved unless the impact of an aging population is built into the new framework. With this in mind, the strengthening of joint commissioning arrangements between health and social care and a timeline for when this should be achieved would be welcomed. The co-location of key staff from the NHS and social care would facilitate this, as would improved and `joined-up' workforce planning. It is essential that any review of the NHS takes full account of the social and other care needs of the population.
As regards non-emergency services for elderly and vulnerable people, we should like to see a strengthening of both local discretion as regards priorities and democratic scrutiny. Both local government and the NHS need to be able to work flexibly to deliver high quality, targeted community services. Clarity about the role of the NHS in early intervention would be welcomed together with a greater emphasis on the role of the NHS in securing well-being and enhanced quality of life.
In social care, we can bring to the table extensive experience of commissioning, together with well-established mechanisms and expertise for consulting with users (patients) and carers. For many people, their contact with NHS professionals is short term (if expensive) but for the services we deliver their contact is long term and, often, life long. If we fail to respond adequately to people's long term, social care needs, there is a very real risk that they will re-present to the NHS via A&E or other means.
As regards emergency, secondary and tertiary care services, Hampshire County Council strongly believes that there should be a more secure emphasis on the "national" element of the National Health Service in recognition of continuing public concern about "post-code lotteries". We also believe faster and more consistent progress needs to be made with "choose and book" and associated initiatives so that patients are empowered to manage their own access to services. To this end, we welcome the idea of a constitution for the NHS which balances both the rights and responsibilities of patients/service users to allow local discretion within a clearly defined national framework.
In addition, we would welcome recommendations that address the development of single assessment processes, together with the introduction of patient - held records. Your Interim Report comments favourably on the concept of Direct Payments and individual budgets. Adult Social Care expertise in this area should prove invaluable to the NHS. The concept of including NHS resources within personal budgets is one that we would welcome. For this to succeed, robust single assessment processes will be essential. It will also be necessary for Local Authorities to be sufficiently resourced so that the current differences across the country in respect of the application of eligibility criteria can be smoothed out.
There is also a need to provide - jointly - clear and consistent guidance on key areas such as end of life care and Continuing Care and to do so in a way that the public can understand. Your Interim Report references the need for partnerships between people with diabetes and health and social care professionals. We would go much further than this and include, for example, people with long-term respiratory conditions such as asthma and emphysema among others. This links to our wish to see a much stronger emphasis on the provision of coordinated advice and information so people can access support to maintain independence. We believe this needs to be located at key points where patients come into contact with health and social care services as well as on-line.
Finally, there is an urgent need across both the NHS and social care to strengthen and enhance support for carers both formal and informal, whose role as the population ages is growing in social and economic significance. We cannot afford to ignore the contribution that carers make to enabling people to remain independent and in their own homes and need to be able to support this as fully as possible.
In short, whilst acknowledging the importance of hospital and associated services, we would urge that you consider the interdependencies and links that exist across the full range of health and social care services in coming to your conclusions.
Yours sincerely
Cllr Felicity Hindson
Executive Member for Adult Social Care
cc Cllr Ray Ellis
I. JOINT HEALTH OVERVIEW AND SCRUTINY COMMITTEE - FIT FOR THE FUTURE
Proposals for Accident and Emergency Services
Key Issues Briefing Note (for Members of the Committee Only)
Prepared by Denise Holden, Hampshire County Council and
Saskia Kiernan, Portsmouth City Council
CONTENTS: |
|
Executive Summary............................................................. |
1 |
Full Report |
|
Summary......................................................................... |
4 |
Background...................................................................... |
5 |
The Developing Picture of Accident & Emergency Services............. |
5 |
Recent Discussions about the Future of Emergency Services........... |
6 |
Issues to Consider............................................................... |
7 |
The Organisation of Emergency Care........................................ |
8 |
Urgent Care Centres............................................................ |
12 |
Current Provision and the Consultation Proposals.......................... |
13 |
References........................................................................ |
17 |
Appendix One - Glossary...................................................... |
19 |
Key lines of Inquiry and Possible Areas of Questioning.................. |
20 |
Executive Summary
The Case for Centralisation
1. There is a strong case to support the streaming of some conditions, such as heart attacks or major trauma patients to a specialist facility, detouring to a less specialist unit could adversely affect the outcome for this category of patient. (3,6,12)
2. For other conditions longer journey times could have an adverse impact (11)
3. Evidence for the centralisation of non-complex high volume cases does not exist. (3,12)
4. If specialist services are centralised there needs to be major changes in pre-hospital care to ensure that patients are assessed and transported in an appropriate and timely way.(4,5 12)
5. The consolidation of services will make inter hospital transfers more common potentially increasing risks to patient safety. The resource implications for ambulance services and critical care staff need to be identified and resourced. (4,9,12)
6. Centralisation may have consequences in terms of access and disadvantages for remote and rural communities (5,12)
Alternatives to A&E
7. There is evidence to suggest that that alternatives to A&E (e.g. urgent care centres, minor injuries units) do not have a significant impact on the pressures in A&E- rather these seem to meet an additional unmet need. (6,12)
8. Recent reports highlight that there is no evidence that new ways of delivering emergency and urgent care are more cost effective than existing models. In some cases they may be higher. (12)
9. Access to specialist input may not require a physical location, models of care based on clinical networks, appropriately supported by agreed protocols can provide a significant proportion of the support required. (4,5)
10. Although there is evidence that many cases attending A&E could be treated in alternative settings it is more difficult to identify these prospectively prior to presentation. (3)
Emergency Care Networks
11. The A&E Department is just one element of a range of different services that are able to provide effective emergency/urgent care, it cannot therefore be considered in isolation of other services- such as those in the community or ambulance services. (4,6,12)
12. There is strong evidence supporting actions that can be taken across a health economy to address some of the areas that cause pressures on A&E- e.g. admissions due to falls, management of chronic disease but these need to be taken forward with explicit investment in community/primary care services (1,6.)
13. Many networks are still in their infancy and need authority and funding to operate effectively. (6,12)
14. Clinical interdependencies are key to draw out and address- the current proposals only focus on the population within the SHA boarders. It is not clear if the clinical interdependencies that transcend the SHA boundaries have been considered.
15. Alternative care settings need to be part of a single clinical network, with clearly defined protocols for ensuring that patients receive timely and appropriate care. (5,12)
The Organisation of Care
16. Plans to redesign services which involve moving services from a particular site must not be fully implemented until replacement services are established and their safety audited. This may involve running services in tandem for some time and these extra costs must be factored into plans for reconfiguration. (12)
17. Services for older people, children and those with mental health conditions need particular consideration in terms of assess to A&E services and a networked response to the needs of these patients (1,6).
18. The demand for A&E is predictable, as is the need for critical care in specialist centres. This needs to underpin service planning. (6)
19. Services, such as theatres, and diagnostics need to be considered on the basis of an extended basis rather than the traditional 5-day working week in order to utilise resources services to the fullest extent (4).
20. Hospitals accepting unselected medical emergencies should have access to on-site surgery. (5,12)
21. The Royal College of Surgeons states that ideally the catchment population for an acute hospital- or network of hospitals - with emergency services concentrated on one site- would ideally be 450,00 - 500,00. However as this scale of reconfiguration is considered to be financially and politically unlikely- and undesirable from other perspectives, including access- the Royal College recommends a minimum catchment population of 300,000 (3,5).
22. The recently published report by the Academy of Medical Royal Colleges states that a district hospital (see below), with 24 hour surgical and children's services and possibly maternity services will serve a population of 250,000- 300,000 (12).
23. The British Association for Emergency Medicine and the Royal College of Emergency Medicine suggests that for a hospital to maintain the skills and competencies of staff within an A&E department, it would require an average of 70-100,000 cases a year.
Summary of spectrum of types of care (Taken from Academy of Medical Royal Colleges Report-the exact distribution of services will depend on local needs)
Acute and emergency services
Primary care
Provides assessment and treatment of most less serious acute problems
Community hospital/urgent care centres
Also provides some imaging/tests, simple treatments such as suturing/plaster of Paris
Local hospital
Provides 24-hour services including A&E, acute medicine, imaging including CT,
laboratory services, level 3 critical care (intensive care), general surgery and
orthopaedics where safe. In exceptional circumstances where on-site surgery is not provided, the hospital must not accept unselected medical patients.
District hospital
In addition to local hospital services provides 24-hour specialist services
such as paediatrics, some surgical specialties and possibly obstetrics
District hospital with highly specialised services
In addition to district hospital services will provide highly specialised services.
JOINT HEALTH OVERVIEW AND SCRUTINY COMMITTEE - FIT FOR THE FUTURE
Proposals for Accident and Emergency Services
Key Issues Briefing Note for Members
1. Summary
1.1 There is a strong case to support the streaming of some conditions, such as heart attacks or major trauma patients to a specialist facility, detouring to a less specialist unit could adversely affect the outcome for this category of patient. Other emerging research highlights that certain conditions may deteriorate with a longer journey.
1.2 There is evidence to suggest that that alternatives to A&E (e.g. urgent care centres, minor injuries units) do not have a significant impact on the pressures in A&E- rather these seem to meet an unmet need.
1.3 Access to specialist input may not require a physical location, models of care based on clinical networks, appropriately supported by agreed protocols can provide a significant proportion of the support required.
1.4 The A&E Department is just one element of a range of different services that are able to provide effective emergency/urgent care, it cannot therefore be considered in isolation of other services- such as those in the community or ambulance services.
1.5 There is strong evidence supporting actions that can be taken across a health economy to address some of the areas that cause pressures on A&E- e.g. admissions due to falls, management of chronic disease but these need to be taken forward with explicit investment in community/primary care services.
1.6 Although there is evidence that many cases attending A&E could be treated in alternative settings it is more difficult to identify these prospectively prior to presentation.
1.7 Services for older people, children and those with mental health conditions need particular consideration in terms of using the A&E services.
1.8 There are particular issues related to rural populations that require recognition in order to balance the preferred critical mass of population with access needs.
1.9 Clinical interdependencies are key to draw out and address- the current proposals only focus on the population within the SHA boarders. It is not clear if the clinical interdependencies that transcend the SHA boundaries have been considered.
1.10 The demand for A&E is predictable, as is the need for critical care in specialist centres. This needs to underpin service planning.
1.11 Alternative care settings need to be part of a single clinical network, with clearly defined protocols for ensuring that patients receive timely and appropriate care.
1.12 Services, such as theatres, and diagnostics need to be considered on the basis of a 7 rather than a 5-day week in order to utilise resources services to the fullest extent.
2. Background
2.1 Emergency Medicine deals with the prevention, assessment and management of acute and urgent aspects of illness and injury. It covers patients of all age groups, physical types and behavioural kinds.
2.2 Accident and Emergency Units (A&E), or Emergency Departments, are the dedicated areas in a hospital that are organised and administered to provide emergency care to those in the community who are in need of acute or urgent care. They should be open 24 hours a day seven days a week, be consultant led and have appropriately trained staff to deal with the assessment and management of acute illnesses and injury. Furthermore they should be a focal point for education, research and governance for local emergency care systems.
2.3 An emergency is a condition where the patient is suffering from an illness or injury requiring early assessment and management, either to save life or limb, relieve pain or suffering, or to prevent further deterioration. It is the Emergency Departments responsibility to provide care, or facilitate care, for all patients who present. (`Way Ahead', British Association for Emergency Medicine, 2005).
2.4 A&E departments are also at the border of primary and secondary care. Many patients presenting at an A&E require primary care, while a full A&E service is geared towards the needs of patients with acute conditions that need the facilities of a hospital. Primary Care Trusts, Ambulance Trusts and Acute Trusts should therefore ensure they are working together to ensure a `joined-up' approach to patent care.
2.5 Along side the ongoing transformations in Emergency Care, there has been a centrally driven thrust to improve the performance and response times of ambulances. "Taking Healthcare to the Patient: Transforming NHS Ambulance Services", published in June 2005, set out plans for how the ambulance services could be transformed from a service focusing primarily on resuscitation, trauma and acute care towards becoming the mobile health resource for the whole NHS.
3. The Developing Picture of Accident and Emergency Services
3.1 In 2001 "Reforming Emergency Care" was published by the Department of Health. This sets out a strategic approach for the development of emergency care, in particular reducing the time it takes for a patient to complete their episode of care to within four hours. These changes were mainly geared towards improving processes within A&E departments and introduced the concepts of `streaming' and "see and treat" for less serious cases.
3.2 In 2002 "see and treat" principles were further promoted by the Modernisation Agency. These aimed for patients to be seen by a clinician who can make the relevant decision as early as possible, removing the need for triage in some cases, or developing it to include ordering tests and administering pain relief.
3.3 Following the publication of "Reforming Emergency Care" in 2001, Sir George Alberti published a report called "Transforming Emergency Care in England" in October 2004, which outlined the progress made in improving Emergency Care in England. This report highlighted the improvement made in the previous two years but stressed that this was merely a platform for delivering a radical new service in the future.
3.4 "Transforming Emergency Care in England" sets out plans to develop a clear strategy for delivering a comprehensive, patient-centred emergency care system that transcends the conventional boundaries between primary, secondary and social care. It highlights six principles of patient-centred care:
· Personal, individual, high quality service to patients, wherever it is delivered, according to their needs;
· No unnecessary delays;
· Simple access; patients will have easy to follow and understandable journeys of care, no matter where they enter the system;
· Care will be provided where it is most convenient for patients. 24/7 care, where appropriate, will be available in hospital and community settings;
· Emergency provision: patients will receive care as early as possible. This will help prevent their problems from becoming serious or even happening at all;
· Integrated whole system care: patients will be able to move from one part of the system to another, without barriers, delays or having to start again.
3.5 "Transforming Emergency Care in England" also outlined the way care would be developed around patient needs. It suggested that traditional "boundaries" between primary care trusts, acute trusts, social services, local authorities, ambulance trusts, pharmacies, etc, would need to be broken down to develop new integrated structure.
3.6 Also in October 2004 the National Audit Office published an assessment of the government's drive to both modernise and reduce waiting times in A&E. `Improving Emergency Care in England' (6) found that emergency admissions show less variation than planned admissions- there is therefore a degree of predictability in demand. Further, Trusts have historically planned scheduled admissions, rather than the known emergency demand, around traditional staffing schedules. Intermediate care and arrangements to return patients to their own homes are also key elements of care that needs to be carefully considered.
3.7 In March 2006 the National Leadership Network published `Strengthening Local Services-the future of the acute hospital' Reference and Resources Report (4). This concluded, "Any sustainable future for local hospital services will be about commissioned networks of hospitals working in tandem with community based services providing high quality, local care as part of a whole system- and not about individual hospitals struggling to survive in isolation. It will need to deliver high levels of co-operation and service integration a way that promote competition and choice rather than local monopoly".
3.8 `The Future of the Acute Hospital' (3) also recognised that a failure to engage proactively with service reconfiguration by many smaller hospitals might easily result in a subsequent loss of local service provision. A proactive approach to local reconfiguration would allow the development of strong networked solutions to the provision of innovative secondary care services that are more firmly embedded in community settings- both of which require extensive planning and preparation. It stated that `deferring consideration of service configuration ...may result in decisions being forced under conditions of crisis...with crude centralisation and consolidation at major centres without the development of new and innovative local services.'
4. Recent Discussions about the Future of Emergency Services
4.1 Sir George Alberti published his views on `Emergency Access- case for Clinical Change' in January this year. He outlined proposals for a `pyramid' of accessible urgent care facilities including GP out-of-hours services, pharmacies, social services, mental health teams, urgent care centres and the voluntary sector. At the top of the pyramid would be specialist services, followed by regional acute hospitals with 24 hour consultant cover- termed `super A&Es'. He also suggests that `patients ...will be dealt with in an urgent care centre - currently called either a walk in centre or a minor injury unit.'
4.2 The Institute of Public Policy Research published `The Future Hospital' (3), also in January 2007. This analysed the drivers behind hospital change and the politics of acute reconfiguration. In examining the national evidence around A&E admissions the report states that `while emergency care for people with severe illness or injury needs to be concentrated in acute hospitals with the necessary specialist staff and equipment, much of the urgent care currently provided by A&E hospitals could also be provided more locally'.
4.3 The Academy of Royal Colleges (12) has now published a paper setting out how acute care, including emergency services need to be organised in the future. This document is clear that whilst change is required in some areas this needs to be organised at a high level by managed clinical networks to ensure the co-ordination of services. It also comments that most district hospitals should be able to provide `full emergency services but with better integration of OOH services, WiCs and MIUs'.
5. Issues to Consider
5.1 In summary, the recent developments in thinking around the emergency care agenda indicate that developing effective emergency care networks, incorporating the full spectrum of provision (e.g. primary care Out of Hours, NHS Direct, ambulance services, local A&E services and more specialised centres) will be especially critical to the design of viable new models of acute hospital configuration (4) (6) (12).
5.2 Further improvements to the care patients receive in A&E will depend on addressing the way the whole hospital and other health and social care provider's work to manage the flow of patients. Whilst there are examples of services becoming more patient centred, full integration of services has yet to be achieved.
5.3 The introduction of Payment by Results may possibly generate incentives that cause certain hospitals to draw back from establishing strong networks, in order to maximise revenue: similarly the autonomy of Foundation Trusts may make them reluctant to cede authority or resources to networks. Important tensions between governance and the effective operation of networks remain unresolved across all NHS organisations (4).
5.4 Work is also currently underway with the DoH and Royal Colleges to define clinically safe pathways within primary care for dermatology, ear, nose and throat medicine, general surgery, orthopaedics, urology and gynaecology. It is envisaged that this will in part be achieved by introducing a new generation of community hospitals and facilities with strong ties to social care (4).
5.5 Cost effective new models of care will need to contribute directly to efficiency and sustainability as lower annual growth in funding is expected from next year (4).
5.6 A&E must be considered an essential service that patients expect to access locally (5). The public expect to be able to access unscheduled care via A&E and the Department of Health, in `Reforming Emergency Care' has stated that NHS staff should not consider any patients attending A&E to be `inappropriate' (6).
5.7 Although underlying population morbidity is not increasing more patients are presenting as emergencies particularly for conditions relating to heart and respiratory disease (1) with evidence that elderly are being repeatedly admitted- possibly as a means of managing chronic conditions. The 4 hour waiting time target has increased the number of patients admitted (and in Foundation Hospitals particularly this will generate income). The organisation of facilities should not be by specialty but a combined medical and surgical assessment team to ensure patients are directed to the right care.
5.8 More lives can be saved if some conditions-such as heart attacks and major injuries are centralised in specialist hospitals (3). Some life saving surgery needs to be centralised but urgent care for minor injuries and health problems-which make up the majority of A&E cases- can be provided locally (3). If patients with some complex problems are treated in local general hospitals then the research suggests they are less likely to survive (3). This is not a universal fact though and many procedures can be carried out locally at a DGH, community or even clinic level. Strong evidence for centralised services exists for major surgery, such as cardiology, neurosurgery, liver transplantation, some cancer surgery and major vascular surgery.
5.9 The Medical Care Research Unit at University of Sheffield recently published the results of a study into the effects of increased ambulance journey times on seriously ill patients with respiratory problems (11). The study was based on a review of life-threatening (category A) calls to four ambulance services in England, representing urban, rural, mixed, and remote areas, between 1997 and 2001 and found that the further some seriously ill patients have to travel by ambulance to reach emergency care, the more likely they are to die. It is therefore essential that there is clarity about how seriously ill patients are routed to the right services to ensure that optimum care is provided.
5.10 The Royal College of Surgeons states that ideally the catchment population for an acute hospital- or network of hospitals - with emergency services concentrated on one site- would ideally be 450,00 - 500,00. However as this scale of reconfiguration is considered to be financially and politically unlikely- and undesirable from other perspectives, including access- the Royal College recommends a minimum catchment population of 300,000 (3) (5). The Academy of Royal Colleges suggests that a district hospital should serve a population of between 250,00 and 300,000 people.
5.11 Whilst it is recognised that specialist care cannot be provided in every hospital centralisation has often created severe (and avoidable) congestion at the central unit, coupled with difficulties in discharge planning. In addition it is reported that, in terms of clinical outcome, little is gained (5). Where there is evidence to suggest a positive relationship between large volumes of activity and clinical outcomes, as is the case with some highly specialised surgical interventions, and then the centralisation of services must take place (5).
5.12 Identified benefits should be considered when redesigning services and the relationship between volume and outcome should not always be used to support the centralisation of services- a critical mass of patients can also be met using the managed clinical network approach across geographical areas (5). Careful consideration needs to be given to the needs of rural communities when considering centralisation as these need to balance the distance between sites in order to protect local access.
6. The Organisation of Emergency Care
6.1 The bulk of non-complex conditions seen in an A&E Department can be redirected to Urgent Care Centres (doctor led), minor injury units (nurse led) or in primary care (3). Essentially these facilities could deal with the majority of patients who do not need trauma, resuscitation or emergency surgery. Whilst UCCs, MIUs or Walk in Centres may provide an alternative to a fully equipped A&E service in practice these have not significantly reduced demand on A&E services (3),
6.2 These new sources of emergency care are mainly addressing unmet demand rather than taking the pressure off existing services (6). Minor injury units, co-located with an A&E Department can provide alternatives for people requiring unscheduled care as well as having the advantage of prompt referral to specialist and shared support services. Generally nurse led these Units have been shown to provide as safe and good quality of service as GPs and NHS Direct for minor conditions (6,12).
6.3 There is some evidence that patients using A&E for primary care needs may be associated with the availability of appointments or changes to out of hour's services. Other factors include the perceived seriousness of the condition or perception that the care provided would be better (6).
6.4 Alternative care settings- whether MIUs, Walk in Centres or Urgent Care Centres need to be clearly defined to ensure that there is no misunderstanding across the different levels of service providers (9). There needs to be clarity in areas such as critical care about what could be provided in a Local General Hospital as opposed to a Major General Hospital. Other services provided on these sites may be impacted on (e.g. intensive care, anaesthetics) and this needs to be addressed in any planning of service reconfiguration. (9). Supporting work is likely to be required with regard to
· Integrated care pathways
· Communications strategies
· Information and IM&T
· Workforce and training
6.5 Many admissions through A&E are not necessarily the best route for the patient. While there are estimates of non-urgent A&E visits constituting up to 80% of workload there are other studies that suggest only 8% of patients who arrive in A&E could have been diverted in advance- i.e. although retrospective reviews of patients notes identified that many patients did not need acute treatment, this was not necessarily predictable in advance. (3).
6.6 Emergency Care Practitioners (ECPs) enables ambulance professionals to respond to the 90% of calls that do not require emergency treatment, identifying those that can be cared for in alternative settings (3). There are however a range of models of this role in use- making it difficult for practitioners to transfer and differences in skills and competencies (6).
6.7 Some research suggests that distance to hospital is a small factor in determining people's overall access to healthcare (3). Costs (in terms of time effort and money) are more important and offset against the perceived benefit. Access to primary care is more significant than access to secondary care. Other factors, such as differences in referrals may be more significant in terms of access to secondary care services. It can be argued that the current hospital centred health system reduces access to services that are better provided in community settings.
6.8 Emergency Departments are vital components of local urgent care networks, delivering acute and emergency care, in close coordination with ambulance services, walk-in services, GP out-of-hours services and other emergency intervention services (4). In order to provide safe 24/7 emergency services there should be immediate access to intensive care, anaesthetics, acute medicine, general surgery and orthopaedic trauma (3).
6.9 While very few patients require an immediate operation, patients do require immediate expert assessment (5). A&E departments must be staffed by appropriately trained A&E specialists, supported by a trauma team and appropriate diagnostic and anaesthetic facilities.
6.10 Wherever possible, emergency / assessment services should be "streamed" separately from elective services, i.e. a physical separation of facilities, resources, and personnel; personnel with emergency care responsibilities should be freed of elective / non-emergency commitments while on duty (4). Consultant surgeons on call from general surgery and trauma must be free of all elective commitments. Unselected medical take without the ability to provide on-site surgical opinion is unsafe (5,12). Appropriate transfer and by-pass protocols will be required for those centres that cannot offer the full range of services (5).
6.11 The British Association for Emergency Medicine and the Royal College of Emergency Medicine suggests that for a hospital to maintain the skills and competencies of staff within an A&E department, it would require an average of 70-100,000 cases a year. It states that anything less than this would make it hard for the department to maintain an adequate clinical workload and attract the high quality clinicians necessary for a good service. NB: This is acknowledged by the Clinical Reference Advisory Group in the Consultation Papers. (`The Way Ahead'. British Association for Emergency Medicine, 2005)
6.12 The particular needs of children, older people and patients with mental health problems need to be assessed in terms of facilities, access to specialist advice and staff training needs. Emergency care networks are one route through which this work can be progressed (6).
6.13 The ability to provide fully-staffed 24/7 critical care is likely to be the key determinant of the range and complexity of emergency services which can be provided on-site; critical care for key groups (e.g. paediatrics) will require networked provision across multiple providers (4). Access to beds needs to be considered. The timing of admission and discharge is a key factor in this respect.
6.14 Integrated assessment services should be developed, based on the "See and Treat" principles referred to above. That is single assessment by a highly-skilled professional, allowing rapid definitive diagnosis, early initiation of treatment, and appropriate delegation of further diagnostic and treatment tasks to skilled professionals (as opposed to the patient seeing the most junior member of staff and then having their care escalated) (4). A&E medical staff can usually decide whether a patient needs admission and to which ward but traditionally they have had to seek permission from a physician on the relevant admitting team, sometimes more junior than themselves (6)
6.15 Maximum use should be made of the day and the extended evening to provide diagnostic, treatment and rehabilitation services, and training activities, while a very different pattern of activity is supported at night, with staffing requirements varying accordingly (4).
6.16 Access to specialist staff and services should be maintained over the weekend to reduce the risk of adverse events and to provide continuity of care (4).
6.17 Multi-disciplinary teams provide staff in flexible combinations appropriate to cover the full range of relevant competencies, rather than in a set combination of professional disciplines (4).
6.18 All local hospitals should be active members of multi-hospital networks of care. Urgent care, emergency surgery and trauma (alongside specialist surgery, obstetrics and gynaecology, paediatrics and so on) will need to be provided via well-defined and accountable multi-hospital care networks, with mutual support and interdependence becoming essential as several key service areas become increasingly impossible to staff or sustain on a 24 hour basis at every local hospital (4).
6.19 Ambulance services will play an essential role in ensuring safe, reliable and speedy routing of patients to the most appropriate provider (4). In managed networks care is delivered seamlessly via a chain of individual but interconnected healthcare practitioners. Such arrangements can prove challenging for service management in that networks often develop across traditional employment boundaries, creating virtual organisations of service, but are essential in providing some specialised surgical services. Networks can help remove or avoid unhelpful barriers between primary and community. There are concerns about patient safety accountability, clinical governance and risk management. Clinical networks must be effectively managed, roles and responsibilities clearly define and protocols of care agreed across all health professional operating in the network.
6.20 Many networks are still in their infancy and lack the authority and funding to bring about co-operation across various providers of care (6).
6.21 All local proposals for specific service configurations and for the identification of which services are required locally to support an A&E department must include a detailed patient safety risk assessment as an integral part of the design process.
6.22 A fully functioning 24/7 A&E requires a critical population mass (5). This unit should provide for training of junior staff and link effectively with the base hospital, neighbouring DGHs and peripheral centres to allow for the effective management of all conditions.
6.23 According to the British Association for Emergency Medicine (BAEM) reconfigurations of service can have a dramatic effect on the provision of emergency medicine. The present trend is towards establishing a network of urgent care centres feeding to a central Emergency Department. However, the BAEM stresses that a minor injury service or urgent care centre will not provide the same service as an Emergency Department. The BAEM states that any decision on reconfiguration needs to be fully informed of its potential impact on emergency care in the community.
Proposed MINIMUM range of acute services required on-site to support the operation of an Accident & Emergency Department in a Local Hospital (4)
Accident & Emergency Department |
Supported On-Site By 24 Hour Access to: |
Acute Medicine Level Two Critical Care Non-Interventional Coronary Care Unit Essential Services Laboratory (ESL)1 Diagnostic Radiology2 |
Supported by 24 Hour Local Multi-Hospital Network Access (not necessarily on-site) to: |
Emergency Surgery Trauma & Orthopaedics Paediatrics Obstetrics & Gynaecology Mental Health Specialised Surgery3 Interventional Radiology |
Notes:
1 ESL comprising rapid access to biochemistry, haematology, blood transfusion, basic microbiology, infection control and mortuary services
2. Comprising X-Ray, ultrasound and CT Scan
3. The same rationale of networked support in the identified services also applies to a wide range of other specialised services
7. Urgent Care Centres
7.1 Over the last decade there has been the introduction of Urgent Care Centres (UCCs), also known as Minor Injury Units (MIUs) or and Walk in Centres (WiCs). There is no universally agreed definition of a UCC although the need to address was recognised in `Direction of Travel for urgent care' (2006). This document defines urgent care as
7.2 `..the range of responses that health and social care services provide to people who require- or who perceive the need for- urgent advice, care treatment or diagnosis. People using these services should expect a 24/7 consistent and rigorous assessment of the urgency of their care need and an appropriate and prompt response to that need'.
7.3 "Our Health, Our Care, Our Say", published by the Department of Health in 2006, developed a range of ways in which patients with less serious injuries and illnesses could be taken out of A&E departments to Urgent Care Centres, and consequently closer to peoples homes.
7.4 The Urgent Care Clinical Reference Advisory Group (CRAG) notes that the public generally do not yet recognise the term Urgent Care Centre but do have some understanding of the following:
· Walk in Centres: open access treatment service offering minor injuries and illnesses service
· Minor Injuries Unit: A unit dealing with non-life threatening injury often led by experienced nurses or GPs
7.5 This document sets out some of the features of a Urgent Care Centre which were used to inform the modelling described be the CRAG, including:
· May be run by nurses with medical cover (skilled in A&E and part of a county wide A&E service regardless of place of work)
· Supported by X-ray & Diagnostics (ultrasound, blood analysis probably including blood gases)
· With Out of Hours services, social services, mental health & community / intermediate care, emergency care practitioners - to help keep people at home / get them back home
· As part of a county wide service / network (from A & E at Major General Hospital to ambulance)
· Providing governance & staff rotation to maintain skills
· With access to short term beds (12 - 18 hours used e.g. to prevent the need to admit to hospital for social reasons because an elderly person living alone arrives late at night). This might be part of the Urgent Care Centre or use some beds in a nurse led intermediate care unit.
· Dealing with more minor but common cases (such as minor GP referral, GCS >14) common fractures, non cardiac chest pain or shortness of breath, faints, urinary catheterisation, etc.)
· Probably open 24/7 (depending on local need)
· Could form the front end of a main A&E department or be `stand alone'
· Likely to need a throughput of at least 30,000 cases a year to maintain staff competence.
7.6 Unscheduled care is closely linked with but different from A&E services. Care of this nature relates to any event that is unplanned or unscheduled where an individual is seeking attention from a health or social care professional. There are frequently multiple points of entry to these services, which may include attendance at an A&E Department, Out of Hours services, social care, mental health ambulance services community and primary care.
7.7 Changes to the national GP contract have meant that outside core hours (normally 8 a.m.- 6 p.m. Monday to Friday) many GP practices are not available for routine appointments and calls go to the Out of Hours (OOH) service. This can be delivered in a variety of different ways.
8. Current Provision and the Consultation Proposals
8.1 The current provision and activity of Accident & Emergency Care across all the areas affected by the consultation process is set out in the West Sussex PCT document "Activity Flows July 2007". Currently there are A&E departments situated at Queen Alexandra Hospital in Portsmouth, the Royal West Sussex Hospital in Chichester, Worthing Hospital, the Princess Royal Hospital in Haywards Heath, the Royal Sussex County Hospital in Brighton, and the East Surrey Hospital in Redhill. These are supported by a network of minor injury units and walk in centres at Littlehampton, Bognor, Horsham, Crawley, Portsea Island and East Grinstead.
8.2 Option A proposes that the A&E departments at Chichester and Haywards Heath would be downgraded to walk in centres or minor injury units (urgent care centres). Options B and C propose that the A&E departments at Haywards Heath and Worthing be downgraded to urgent care centres, attached to different models of hospital. All three options assume that the A&E departments in Portsmouth, Redhill and Brighton will be able to cope with the increase in operations.
8.3 The papers considered by the West Sussex PCT Board on 25 June 2007 as background to the commencement of the consultation process included a report from the Clinical Reference Advisory Steering Groups sub-group for Accident & Emergency/Urgent Care (10). This sub-group, chaired by Dr Peter Hayward, a Public Health Consultant, investigated the implications for Emergency Care if West Sussex only had one Major General Hospital. Key to the sub-groups considerations was that the service was safe, affordable and accessible.
8.4 The Reference Group papers outline that government and professional policy, the European Working Time Directive1 and Modernising Medical Careers2, would support changes to Emergency Care services, with more local and minor care centres being introduced to complement A&E. It notes that national guidance on staffing levels and workloads suggest that the population of West Sussex would only support one Accident & Emergency (A&E) unit with associated Major General Hospital (MGH). The report also states that `currently WASH and St Richards consider themselves to be broadly EWTD compliant for A&E'.
8.5 The CRAG report also indicates that special consideration should be given to the spread of deprivation and the elderly when deciding the geographical location of the A&E unit and supporting minor centres. It indicates that most of the population, deprivation and elderly are located in the south of West Sussex. The report acknowledges that there are plans for major development in the north of the county but it is not clear if these anticipated increases have informed the modelling undertaken. The report notes further work is required to refine patient flow data and the impact on ambulance services.
8.6 The full report (paragraph 2.6) highlights the conflict between the need to improve access to services, reduce waiting times and reduce ambulance response times, with having appropriately staffed departments to deal effectively with the serious cases.
8.7 The report includes an analysis of access and ambulance response times. However, but it is not clear if the CRAG were familiar with the claims made about journey times and their impact on some patients in the University of Sheffield research as mentioned above. The papers do note that "as road traffic continues to increase, travel times may also increase" and modelling patient flows is examined. It is not clear if there has been a traffic assessment given to substantiate this statement and the report also comments that "few studies are helpful in predicting workload redistribution locally". Without this information it is hard to scrutinise what the impact will be on residents in West Sussex, Surrey, East Sussex, Brighton & Hove, Hampshire and Portsmouth.
8.8 Appendix B to the Reference Group Report examines the ambulance notes of patients bought to A&E in Worthing and Chichester during the first two weeks of June 2006. However, the report goes on to acknowledge that this information cannot be extrapolated to provide annual figures and that ambulance case notes are not always accurate. For a judgement on the potential impact of the proposals on the performance of the ambulance services to be made, annual accurate figures would be required.
8.9 Further the assumptions for modelling undertaken by the CRAG are based on that Brighton and Portsmouth being able to accept any increase in workload resulting from the modelling undertaken. However, correspondence received from Portsmouth Hospitals NHS Trust can only support this case to an extent. The Trust states that in order to meet the additional A&E demand it would require additional bed capacity and resources to accommodate emergency admissions and the increased numbers of people accessing Accident & Emergency services. Prior to a feasibility report, initial calculations indicate that the Portsmouth would require a larger Accident and Emergency Centre. It is not clear how the capital and revenue costs associated with this would be funded.
8.10 Appendix C considers the implications of having two A&E's in West Sussex. This states that the implications of two A&E's are "increased costs offset against better quality care and increased access for patients and the ambulance". It also states that with two A&E's it would be "easier for staff to follow protocol to ensure that the patient is delivered to the right site and quicker turn around times". Sufficient staffing is in place to manage two A&E departments.
8.11 Agenda paper 44/07, considered by the South East Coast SHA on 25 June 2007 discusses the proposals put forward by West Sussex and Brighton and Hove PCTs in detail (see also West Sussex PCT Board Papers, 25 June, Item 3). This paper notes the importance of the ambulance service in the reconfigurations proposed (3.46) but states that no significant change requiring consultation is proposed. It estimates that the overall impact on activity levels (page 28) will be as follows:
· Outpatients- reduced by 37%
· A&E attendances reduced/redirected by 67%
· Non elective admissions reduced by 24%
· Elective admissions reduced by 14%.
8.12 The estimated gross savings from admissions reduction through emergency care centres is set at £17 million, with the cost of reproviding services estimated at £500,000. Savings are also identified across a range of unscheduled care including community matrons, falls services and COPD community services. Evidence reviewed in preparing this paper for the JHOSC suggests that there is conflicting data about the extent to which patients can redirected from A&E and unplanned admissions reduced by the amount suggested.
8.13 A number of questions have been raised in relation to critical care and what levels can be provided in a Local General Hospital as opposed to a major general hospital. These services are already under pressure and there is an existing unmet need on general wards. The presentation from critical care clinicians suggests that they anticipate that pressures on these services will continue to increase- even if the anticipated reduction in acute hospital admissions is achieved (9).
8.14 In its strategy for providing unscheduled care in its area Brighton and Hove PCT (B&HPCT) note that national A&E attendances in 2003/04 showed a 6% growth from the previous year. Rates of growth identified by B&HPCT in 2006 were above the national average for 2003/04, running at 9% and estimated at 7% in 2004/05. In particular there were large increases in minor attendances (19% in 2003/04 and a projected 17% in 2004/05) (8).
8.15 In 2004/05, 7 primary diagnoses accounted for 43% of admissions in the Brighton and Hove area, underlining the links with chronic disease management:
· Respiratory
· Heart
· Mental health
· Falls
· Urinary
· Cancer
· Poisoning (8).
8.16 The PCT also notes that
8.17 `between November 2003 and October 2004, 1,436 Brighton and Hove registered patients aged over 65 were admitted twice or more resulting in 3,568 emergency admissions.'
8.18 `More detailed analysis of a subset of this patient group i.e. patients with 3 or more emergency admissions and 3 or more A&E attendances, demonstrates that whilst 53% of patients received some kind of input from social care and community services, much of this care was uncoordinated and reactive and still resulted in multiple admissions and attendances in A&E'.
8.19 The report comments that current provision of unscheduled care services within Brighton must therefore be seen in the context of:
· a downward trend in the number of emergency bed days but high numbers of patients whose admission could have been prevented
· 1,400 patients identified as very high intensity users of services (VHIUs) who could benefit from more planned and coordinated care
· increases in A&E demand and limited capacity for expansion within the existing A&E site
· lack of primary care alternatives to secondary care
· lack of primary care access to hospital based tests and investigations and general lack of connectivity between secondary and primary care service delivery
· a broad range of out of hours and unscheduled care provision in the city but with multiple access points, inconsistent referral criteria and duplication resulting in confusion for both the patient and the referrer' (8).
8.20 An analysis of progress with the implementation of this strategy in September 2006 identifies a number of risks which included issues relating to workforce, infrastructure in primary and community settings, increasing A&E activity and people with mental health problems. Members will wish to be clear how these factors have been addressed in the proposals before them.
References
1. `The Future of Acute Care'. Black Andy, NHS Confederation 2006.
2. `Emergency Medicine'. BMA. January 2007.
3. `The Future Hospital'. IPPR. January 2007.
4. `Strengthening Local Services-the future of the acute hospital'. Reference and Resources Report. National Leadership Network. March 2006.
5. `Delivering High Quality Surgical Services for the Future': Consultation Document.' Royal College of Surgeon. March 2006.
6. `Improving Emergency care in England'. National Audit Office. October 2004.
7. `Emergency care in England'. Emergency Network Questionnaire. National Audit Office.
8. `Strategy for the Provision of Unscheduled Care in Brighton and Hove'. Brighton and Hove Teaching PCT. July 2005.
9. `Settings of care'. Critical Care Sussex Network (presentation). May 2007.
10. `Urgent Care Clinical Reference Group Report
11. ``The relationship between distance to hospital and patient mortality in emergencies: an observational study´, the Emergency Medicine Journal, August 2007
12. `Acute health services' Report of a Working Party. Academy of Medical Royal Colleges. September 2007.
Appendix One
Glossary
24/7 (24 hours a day, 7 days a week)
Accident and Emergency Units (A&E)
Hospital departments that assess and treat people with serious injuries and those in need of emergency treatment.
Acute Care
Specific care for diseases or illnesses that progress quickly, feature severe symptoms and have a brief duration
Chronic Obstructive Pulmonary Disease (COPD)
A combination of lung disease, emphysema and chronic bronchitis restricting airflow
Clinical Reference Advisory Group (CRAG)
Critical Care
An integrated service for critically ill patients when they are in the health system
DoH (Department of Health)
Elective Care
Non emergency of planned care that may take place on a day patient or in patient basis
Emergency Care Practitioners (ECPs)
European Working Time Directive (EWTD)
As part of the Working Time Regulations, the Directive states that by 2009, training doctors will by law not be expected to work more than 48 hours a week.
Foundation Trusts
NHS hospitals that are run as independent, public benefit corporations, which are both controlled and run locally.
Information Management and Technology (IM&T)
Intermediate Care. Services designed to assist the transition from medical/social dependence to day-to-day independence
ISTC (Independent Sector Treatment Centre) Programme
Part of a major initiative to create additional capacity within the NHS to reduce waiting times and introduce choice for patients.
Minor Injury Units (MIUs)
A somewhat misleading name because a minor injuries unit can treat the results of most accidents and emergencies. Designed to offer fast advice and treatment (see also UCC).
NHS Direct
A service providing 24 hour access to health information and clinical advice, via telephone, the NHS Direct website or the NHS Direct Interactive digital TV service.
Out of Hours (OOH)
The patient services provided by GPs outside of normal surgery hours (i.e. overnight, at weekends)
Primary Care
The collective term for all services which are people's first point of contact with the NHS, e.g. GPs, dentists
Secondary care
The collective term for services to which a patient is referred to normally by a GP. Usually this refers to NHS hospitals in the NHS offering specialised medical services and care.
Urgent Care Centres (UCCs)
A somewhat misleading name because a minor injuries unit can treat the results of most accidents and emergencies. Designed to offer fast advice and treatment. Nurse led but integrated with GP out of hours and networked with other hospital services to give quick access to senior medical opinion. Able to treat problems such as cuts, bruises, scalds, broken limbs, minor head injuries and falls.
Walk in centres (WiCs)
Centres staffed by nurses that offer patients fast and convenient access to treatment and information without an appointment
Key lines of inquiry and possible areas of questioning
1 Access, including ambulance and public transport, car parking issues, waiting times etc as well as 'hard to reach' groups
PCT
· How have access issues been evaluated including the needs of people in remote/rural communities
· What consideration has been given to population density and travel times in drawing the proposals together
· What work is in place to prevent avoidable admission to hospital- please provide details of the impact of this work across the areas affected by the Fit for the Future proposals.
Service Providers/Others
· What impact do you consider that the proposals will have on access to emergency services for local people
· Are you aware of any implications for your service associated with longer journey times or discharge arrangements
· How will vulnerable groups be affected e.g. older people, people with mental health problems
· Are there enough community services in place to ensure that admission can be avoided- what work is in place to support these arrangements and how is their impact being assessed
2 Workforce and training implications associated with the proposals and in primary/community care)
PCT
· What is the pattern of coverage of community matrons at present and how is this to change under the proposals
· What are the workforce/training implications of the implementation of the proposals for staff working in primary/community care settings
Acute Service Providers
· What is the pattern of cover 24/7 in your A&E department
· To what extent are the current services EWTD compliant- if not how is this to be achieved
· What are the workforce implications of the proposals for you with regard to doctors, nurses, radiographers and other support staff
· What are the implications for critical care services
OOH Providers/PCT
· Does the current OOH provision achieve all the required quality standards
· How does this service link with other providers of unscheduled/emergency care
Ambulance Trusts
· What numbers of ambulance staff are being trained to be ECPs, how is this expected to increase on a year on year basis.
· How is the effectiveness of this training being evaluated in practice and how is this being funded.
General
· How well developed are the relevant local clinical networks (especially urgent/emergency care, critical care paediatrics)- can this be evidenced through authority and dedicated resources
· How will staff work across organisational boundaries
· What are the implications for existing consultant led teams of the proposals- what changes to staffing is envisaged
3 What is the impact on other services including community and primary care, neighbouring service providers adult services, of the options presented.
PCT
· What education programmes are planned to ensure that the public is aware of how to access emergency care should one of the options presented be implemented - what resources have been identified to support this work
· To what extent will there be 24/7 access to diagnostics, radiology and pharmacy services in the different care settings envisaged by the proposals. What is the current position and how will this change
· What are the links with local primary care services, especially OOH care, in the models of care described
· Where intermediate care beds are currently provided in community settings and how will these be affected by the options presented
· What progress has been made with identifying extended clinics in primary care during weekday evenings and the introduction of Saturday clinics for routine appointments
Critical Care Hospitals/Ambulances Services
· How has the PCT engaged in discussion with you about the impact of these proposals and when
· Is it correct to assume that you will be able to absorb the additional emergency and other work suggested in the proposals
4 The evidence base supporting the proposals including demographics
PCT
· Given that no equality impact assessment has been undertaken- what steps have there been to ensure socially excluded groups are not further disadvantaged by the options presented
· What patient safety risk assessment has been undertaken in developing the options
Acute Providers/Others as appropriate
· What year on year increase has there been in workload in A&E (say last 5 years).
· Is there any correlation between the transfer of OOH responsibility and increases in workload
· How is elective and emergency care currently organised.
· Do you have dedicated emergency teams, without elective commitments
· Are there dedicated emergency theatres available over an extended working day
· Is there a surgical assessment unit in your emergency department
· What percentage and type of admissions can most effectively be reduced and how will this happen
· What is the incidence of repeat admissions and how is this being managed
General
· What account has been taken of the needs of older people in shaping the proposals
· What is the assessment of the need for intermediate care beds associated with the different options
· What agreement has been reached with GPs with regard to additional clinics. How will this be funded
· What percentage of admissions are attributed to falls and how is this being addressed
· What consideration has been given to the way in which people with mental health needs access and use the services. How will the options identified respond to these needs
· How have the access needs of people living in isolated/rural areas been taken into account. How is this different from the needs of urban populations.
5 What are the resourcing shifts associated with the proposals, both into community/primary care and out of acute care
· General question for all witnesses to test understanding of how these shifts would work
· How will the proposals impact on the Trusts applications for Foundation Trust status
6 Clinician networks and clinical support for the options presented, including GPs-
General/as appropriate
· What clinical networks will be in place to support the proposal
· Will there be rotation of staff- how will this be achieved across different employers
· Are any aspects of the models proposed contested by clinicians
· What is the level of support from GPs
· Is there currently an Emergency Care Network, if so what arrangements are in place to support it and what organisations are involved
· What resources support the network
· How is work managed across organisational/professional boundaries
· Has the network considered the impact of changes in GP/OOH cover on other providers of emergency care.
7 What are the year on year improvements to be achieved in the quality of care and how this will be evaluated
General/as appropriate
· How will the changes proposed improve patient safety and the quality of care provided.- What evidence base supporting this
· What changes are required in current unscheduled care services to replace services if any of the proposed models of care are implemented
· What plans are in place to audit the safety of the proposed service reconfigurations and over what period of time
· Where will non complex care be directed in the proposals- what changes will be made to pre-hospital care to ensure that patients are assessed and transported appropriately
· What are the risks associated with the proposals
· How will longer journey times impact on patients
· What protocols are in place to ensure that patients are directed to the service most appropriate to their need
West Sussex `Ft for the Future' consultation: Response from Hampshire County Council
Thank you for inviting the comments of Hampshire County Council on the above proposals to reconfigure health services in West Sussex. I am aware that Councillors from our HOSC are actively involved with the Joint HOSC and that you have been able to hear evidence from a number of Hampshire NHS organisations.
Whilst the impact on services provided by the County Council will be limited there is potential for the option downgrading services at St Richards Hospital to significantly adversely affect Hampshire residents needing to access emergency care. This is an issue that the JHOSC will wish to fully consider in coming to a view about whether the proposals are in the interests of the entire population affected. In particular, I would ask that the JHOSC satisfies itself that the PCT has been able to demonstrate the following to members' satisfaction that:
· The capital and resource consequences of implementing the different options proposed across all organisations affected have been identified and addressed.
· Any changes will be able to deliver care that is equal to, or better than current services
· There is a sound evidence base supporting the proposals and clear clinical leadership across the services affected
· There is appropriate community care, and supporting infrastructure in place before acute services are reconfigured. This includes rehabilitation and social services.
· There will be improved access to services across the communities affected, particularly for the most vulnerable such as older people, people with mental health problems and children
· The financial modelling and demand management assumptions are robust
· That the anticipated changes in the population and demographic profiles of our communities have been fully assessed and factored into the options put forward
I hope you find these comments helpful and look forward to receiving the findings of the JHOSC once it has completed its deliberations.
Key points for feedback to West Sussex PCT for Hampshire and Portsmouth Members
Consultation Content and Process
The JHOSC has already expressed its concerns about the consultation process of the PCT and the content of the documentation produced. These concerns remain although the willingness of the PCT to take into account other options for reconfiguring services is to be welcomed.
We would like clarification of how the alternative options will be assessed in the context of the `hurdle criteria' set by the PCT. We would expect this to be conducted and reported by the OAT, under the guidance of the independent Chairman. If other mechanisms for assessing the options put forward are to be employed then this process needs to be conducted openly and transparently so that local people are clear about the process followed. We would also ask that there is a clear statement about the next steps to be taken by the PCT in taking this work forward.
Options presented for consultation
The JHOSC will continue to receive evidence about the proposals until March 2007 before presenting its views to the PCT. It is essential that the PCT keeps the Committee appraised of the process to be followed once formal public consultation is complete- equally there needs to be clear and regular communications with local people.
Should the PCT consider that there are alternative options for reconfiguring services on the area then there needs to be early discussion with the JHOSC about the scope and duration of any subsequent consultation. These proposals need to be well researched and robust, not presented in a less developed format as was the case with the current consultation. The Committee will not be presented with a `fait accompli' as previously and will expect to see evidence that all stakeholders ( including those outside the PCT boundaries in the NHS and local authorities whose patients are affected) have been engaged in drawing together any proposal(s) to be considered.
Whilst the JHOSC still needs to deliberate and come to a view, we will be considering some emerging themes in depth as this process rolls forward. We felt it might be helpful to apprise the PCT of these as it considers its next steps:
· The need for clarity from the PCT and stakeholder organisation in West Sussex about what is subject to consultation and where there is scope for flexibility. A significant amount of anxiety could have been prevented for people in the Hayward's Health area if for example, it was clear that the Trust would be invited to identify alternative options to that presented.
· The need for clarity about the consequential impact of any reconfiguration outside the county boundaries
· Any options to be supported by local clinicians and a up-to date evidence base
· Clarity about workforce and training issues for the services affected- including sources of funding
· Clear functioning clinical networks operating with input from key stakeholders across the services affected
· Clarity about the way `double running' arrangements would be managed and safety /quality of redesigned services audited
· Evidence of community services in place and the additional investment through which community care will be staffed and funded
· The patient pathways in place to ensure that people are seen by the right, person, in the right place at the right time
RE/ |
|
30 October 2007 |
|
A. Health Overview and Scrutiny Committee | |
Elizabeth 11 Court, The Castle | |
Gareth Cruddace Chief Executive Hampshire Primary Care Trust Regus House, Southampton International Business Park George Curl Way Southampton, SO18 2RZ |
Winchester, SO23 8UJ |
Telephone 01962 847338 | |
Fax 01962 867273 | |
E-mail [email protected] | |
www.hants.gov.uk | |
Dear Gareth
Maternity Services in South East Hampshire: Response to consultation
Thank you for inviting the views of the Committee on the proposals set out in the consultation document published on 24 July. As you will be aware this is an area where both Hampshire and Portsmouth HOSCs have taken an active interest over recent years.
Hampshire HOSC members welcomed the early opportunity to inform and provide feedback on the drafting of the consultation document. This issue has been of significant concern to local people and it is time that there was clarity about the way in which these services will be provided in the future. The HOSC is of the view that this uncertainty has had an adverse impact on the utilisation of birth centres that has been exacerbated by the closures associated with staffing difficulties. This will take time to address and rebuild the confidence of local women. Equally you are aware of our view that the premises underpinning the previous consultation about maternity services on Portsea Island have added to the confused picture of the configuration of maternity services across south east Hampshire.
Noting the decision of Portsmouth PCT that, having gone through a previous consultation about the siting of a birth centre on Portsea Island, no further discussion with local people about a co-located unit at Queen Alexandra was necessary, members are of the view that only a partial picture of demand from local women for this facility will be forthcoming. Whilst this is not an issue that falls within the remit of the Hampshire PCT it is nevertheless a factor that is pertinent to the wider debate about the services to be commissioned from Portsmouth Hospitals NHS Trust. We are fully familiar with the comments sent to you by Portsmouth HOSC about the proposals for maternity services.
From our perspective we are focusing on two key areas of interest:
· Was the consultation process and content adequate in terms of providing a full opportunity for local people and other key stakeholders to contribute to shaping the process
· Is the HOSC of the view that the preferred option is the right one for the population affected
With regard to the consultation process and the content of the proposals put forward, the HOSC is clear that the documentation was thoughtfully produced to provide as much information as possible and widely available. Local people and key stakeholders have been given many opportunities to feed their comments back to the PCT. The Committee is of the view that this feedback must be the primary factor in informing the decision of the PCT about the way forward. We will have not therefore identified a preferred option. There are however a number of points that we feel are material to the future provision of maternity services in southeast Hampshire that do need to be considered. These are set out below:
· The HOSC accepts that there needs to be a threshold below which the units will not be viable or safe for mothers and babies. It is helpful to have this so clearly set out in the document, although there may be a range of factors that need to be considered when assessing the quality of care, over and above the number of births. We have already commented on the adverse impact that uncertainty and closures have had on mothers attending birth centres. It will take time for confidence to be rebuilt in the revised services and we would therefore ask that the PCT is flexible in the first 18 months to two years of operation in order to maximise the opportunities for women to become familiar with the services available. At the same time there needs to be a sustained and targeted communications strategy that can help inform women about the choices open to them- it is vital that GP are engaged in this process.
· The need for a range of options for women in southeast Hampshire will be even more critical if there are changes at St Richards Hospital. Whilst we understand that Portsmouth Hospitals has indicated it can absorb this work it is essential that the choices open to local women are not compromised. Equally, given the pressures on staff, care needs to be taken to ensure that midwives are able to spend the time necessary with women to provide a high quality service. Should a co-located unit be identified as the preferred option, and given that we are not able to ascertain the number of women from Portsmouth who may use this facility, we consider that further testing needs to be done to ensure that women who currently use St Richards can be accommodated if the maternity services from this site cease or are relocated to another part of West Sussex.
· We fully support the decision of the PCT to consult only on the round the clock midwife led model of services. We are aware of the dissatisfaction that has been expressed about other models of staffing for the services and, whilst we acknowledge that midwifery assistants can provide invaluable support to midwives, we do need to make the best use of the specialist knowledge and skills available.
· Whilst we do not believe that the Blackbrook Birth Centre should be refurbished we are of the firm view that the are a number of factors relating to the provision of a birth centre in Fareham Community Hospital that need to be further considered by the PCT. These include:
1. Fareham is the only population with a growing birth rate in the area. It has 110,000 residents (which is much larger than Gosport). There are GOSE proposals for a further 10,000 new homes in the area, which will further increase the demand for maternity services.
2. Account has not been taken of the populations that exist outside the boundaries of the former PCT areas, such as Whiteley, with young and growing populations. Equally, women in the east of Eastleigh and surrounding area may consider such a facility to be an option for consideration that is closer than Ashurst.
3. Should the co-located unit be provided the number of women from West Sussex and Portsmouth that may choose to use that facility is unknown; this could have the effect of restricting the choices open to women from the Fareham area, rather than extending it. We have argued consistently for the provision of a birth centre at Fareham, Gosport and Petersfield and remain committed to this view
4. Fareham and Gosport PCT has previously given an absolute assurance that a birth centre would be provided at the new Fareham Community Hospital. Discussions with local stakeholders about the closure of Blackbrook were also predicated on the provision of these services at the new Community Hospital. We believe that local people therefore have a clear and legitimate expectation that these previous commitments, properly endorsed by previous PCT Boards, will be honoured by the current PCT.
I know that the PCT will be giving the views shared by local people about the proposals full consideration before determining how to proceed. It would be appreciated if we could be provided with an analysis of the responses received for consideration at our meeting on 27 November. It would be most helpful if this could include an indication of the preferred option identified.
Please contact me if this causes any difficulties.
With best wishes
Yours sincerely
Cllr Dr Raymond J Ellis C.Chem FRSC
Chairman, Health Overview and Scrutiny Committee
cc |
Hampshire HOSC members Cllr David Stephen Butler Cllr Brian Bayford Cllr Roger Allen |
Maternity Services for Today, Tomorrow and Beyond in
South East Hampshire
Consultation Report
Acknowledgement
Hampshire Primary Care Trust and Portsmouth Hospitals NHS Trust would like to thank the following groups and organisations for their invaluable advice and help during the 7 months of engagement work that has supported this project:
Local branches of the National Child Birth Trust
Parent Network
Hampshire Children & Families Forum
Surestart Centres across south east Hampshire
Children's Centres across south east Hampshire
Triangle Centre, Liss
Titchfield Community Centre
Treloar College
Councils of Community Service
Teenage Pregnancy Implementation Team
Hampshire Ethnic Minority Achievement Service
Hampshire Library Service
Emsworth Community Centre
Fareham Shopping Centre
Hughmark International
Havant & Waterlooville Market
Lloyds TSB, Petersfield
Thank you for your part in encouraging and enabling so many local people to have their say.
Maternity Services for today, tomorrow and beyond in south east Hampshire
1. Background
Since 2004, maternity services in south east Hampshire have been subject to ongoing discussions with stakeholders, mothers and communities about how best to continue providing a range of affordable maternity care. Feedback from all this work has confirmed the need to provide services that are accessible and which offer real choice for women.
In addition, a detailed review of services by the local PCTs (concluded in December 2006), suggested any changes needed to reflect overall falling (or at best static) birth rates in the area; low usage of birth centre beds; changes to maternity services in adjoining areas and the need to ensure value for money when allocating finite NHS resources.
A key finding of the review was that although 21% of women chose to have their babies in one of south east Hampshire's four birth centres (a high percentage compared to national figures) the three stand-alone birth centres in Gosport, Fareham and Petersfield were being under utilised. This was due in part to intermittent closures and ongoing uncertainty about the future of birth centres which meant they were not an attractive choice for women. The home birth rate in this area is high (compared to national figures) with the latest figures showing that 4% of women have chosen a home birth, more than double the national average.
With local stand alone birth centres currently underused for a variety of reasons not least the on-going uncertainty about their future, it is clear that changes are required. What is also clear is that the women of south east Hampshire are positive about making choices other than the main consultant-led unit for the birth of their baby. We believe this offers an exciting opportunity to redistribute midwifery resources to offer a choice of stand-alone birth centres that provide the kind of service that women will actively want to choose.
For these reasons the PCT has made a commitment to fund three birth centres to meet the needs of women in south east Hampshire. Between July 23, 2007 and October 31, 2007 we have been seeking views on where these centres should be located across south east Hampshire.
2. Proposals for service change
Extensive engagement work took place in the four months prior to the start of the public consultation in order to ensure our proposals reflected local needs and preferences. Local mothers and the clinicians that care for them told us that they want birth centres that are open 24 hours a day, 7 days a week, and 365 days a year staffed by fully qualified midwives. As this was so important to local women we only consulted on maternity care provided using a 24/7 midwife-led model.
2.1 The options
The consultation asked for local views on where these birth centres should be located. The options were:
· Option 1: Blake, Gosport; The Grange, Petersfield and a co-located unit at St Mary's Hospital (moving to Queen Alexandra Hospital, Cosham from 2009)
· Option 2: Blake, Gosport; Blackbrook, Fareham and a co-located unit at St Mary's Hospital (moving to Queen Alexandra Hospital, Cosham from 2009)
· Option 3: Blake, Gosport; The Grange, Petersfield and Blackbrook, Fareham
· Option 4: The Grange, Petersfield: Blackbrook, Fareham and a co-located unit at St Mary's Hospital (moving to Queen Alexandra Hospital, Cosham from 2009)
2.2 Birth rates for south east Hampshire
A recurring theme of the consultation has been the need for the PCT to keep under constant review the projected number of births in South East Hampshire, in order to ensure that the proposals are, and continue to be, responsive to the needs of local mothers. When the PCT published its consultation document in July 2007, the projections (built on data provided by Hampshire County Council) suggested that birth rates were expected to decrease by 7.2% by 2026 (over 300 births per annum). However, the PCT and Hampshire County Council have recently concluded a joint strategic needs assessment which suggests that rather than fall, the overall birth rate of south east Hampshire is predicted to increase marginally by 2026.
This adjustment to the predicted birth rate is applicable to all areas of south east Hampshire, and the revised numbers are set out below.
Area |
Birth rate predicted in consultation document (July 2007) |
Latest birth rate predictions (November 2007) |
Fareham |
+ 130 |
+220 |
Gosport |
- 141 |
- 100 |
Havant |
- 127 |
- 20 |
East Hampshire |
- 165 |
- 60 |
TOTAL |
- 342 |
+ 40 |
These revised projections are presented as evidence of the PCT's commitment to keep the birth rates in south east Hampshire under constant review. Whilst these increases are clearly relevant to the shape of services in the future, they must also be placed into context. In Fareham, for example, the number of births is now projected to grow by 220 by 2026 (as opposed to a growth of 130 births predicted in the original consultation document). This additional growth is important, but at this stage is not deemed significant as it would only translate to just over one additional birth a month in a stand alone unit.
That said, in keeping with our commitment throughout this consultation to be responsive to local views and changing circumstances it is recommended that the Board regularly review birth rates and demand for services to ensure the configuration meets local needs (see section 5.6 below)
2.3 How will the decision be made?
A decision will be taken that ensures we have the right services in the right place by choosing the option that:
1. Ensures choice and good access to services.
2. Takes into account feedback from local people before and during the formal consultation process.
3. Maximises bed usage against a backdrop of changing birth rates.
4. provides an affordable and sustainable future for birth centres in south east Hampshire.
Hampshire Primary Care Trust in partnership with Portsmouth Hospitals NHS Trust will make the final decision.
3. Patient and public involvement and consultation
Patient and public involvement is an essential part of the PCT's business. There is a statutory duty under Section 11 of the Health and Social Care Act to inform and involve patients and the public in the development of plans for change in the NHS. In addition NHS organisations are required to formally consult, under Section 7 of the Act, with the Health Overview and Scrutiny Committee (HOSC) Where the HOSC considers any proposal constitutes a substantial development or variation in the NHS service provided, then the proposals must go out for formal public consultation.
It was against this background that Hampshire PCT, in collaboration with Portsmouth Hospitals NHS Trust, undertook a period of informal engagement and involvement with local communities, stakeholders and staff. This began in April 2007. Further details of this work are available on request from the Consultation Office, Raebarn House, Waterlooville, PO7 7GP. A period of formal consultation followed beginning on July 23, 2007 and ending on October 31, 2007. Details of this formal element are described below.
A team of senior staff, led by Alex Berry Area Director of Commissioning, undertook to ensure the planning and formal consultation processes were robust and appropriate. The Trust Board was regularly updated and given assurance that the Trust was meeting its statutory duties with regard to the Health and Social Care Act.
3.1 Gateway Review
In addition to scrutiny by the Hampshire Overview and Scrutiny Committee, the proposals for a public consultation on maternity services in south east Hampshire were also subject to an Office of Government Commerce (OGC) Health Gateway Review. This took place between 26 June 2007 and 29 June 2007.
The primary purposes of a Health Gateway Project Review are to review the outcomes and objectives for the project and confirm that it makes the necessary contribution to Ministers' or the departments' overall strategy.
The Gateway Project Review Team interviewed a number of PCT and Trust staff together with a range of stakeholders.
The Team concluded that stakeholders were strongly supportive of the direction of the project and staff had been engaged in the process.
The Review recognised the `considerable effort to engage with stakeholders in advance of the formal consultation' and were pleased with arrangements in place for the formal consultation. A number of recommendations were made to the PCT regarding governance of the project and details of the consultation document. These were actioned prior to the commencement of the formal consultation process.
3.2 The formal consultation process (Section 7, Health and Social Care Act)
This consultation has been built on a number of key principles:
· That the NHS would go out to where service users and local people are, rather than expect them to come to us. Thus there has been an emphasis on informal presentations and drop-in events rather than more formal public meetings.
· A similar programme of events was arranged in each locality. This was to ensure each community had an equal opportunity to voice their views.
· It was clear from the informal stage that the factors influencing where local people choose to give birth are complex, particularly in `border' areas on the fringes of south east Hampshire. As a consequence focussed work was undertaken beyond traditional organisational boundaries.
· An inclusive approach taking account of the diverse community of south east Hampshire
3.3 Telling communities & stakeholders about the consultation
Hampshire PCT, in partnership with Portsmouth Hospitals NHS Trust distributed the consultation documentation to stakeholders across South East Hampshire. Both organisations worked closely with staff, maternity service users and key stakeholder groups to ensure they were fully informed. The information was circulated to:
a) Staff and their representatives
b) GPs, practice staff, practice nurses, community nurses and therapists
c) Maternity service users, and their families
d) Members of the public
e) The Portsmouth & South East Hampshire Maternity Services Liaison Committee (MSLC)
f) Councils - unitary, borough, district and county
g) Education establishments, including the University of Bournemouth
h) Patient and Public Involvement Forum
i) Voluntary and community organisations (e.g. National Childbirth Trust, Hampshire Children & Families Forum, Councils of Community Service)
j) Ante and post natal groups
k) Surestart Centres and Children's Centres
l) Other NHS trusts and Primary Care Trusts (inc Hampshire Ambulance)
m) South Central Strategic Health Authority
n) Portsmouth and Hampshire Health Overview and Scrutiny Committees
o) Local MP's, borough & district councillors
p) Media - local, regional and national.
q) Hampshire PCT website
A number of local organisations supported the consultation process by including information about how local people could have their say in their newsletters, as well as distributing leaflets and feedback forms to their members and contacts. This `grass roots' help added significantly to the volume of comments received and to the success of the consultation process overall.
3.4 Ensuring communities and stakeholders had their say
During the informal engagement phase (April to July 2007) a large number of groups, individuals and key stakeholders were involved, and their views and comments were used to help shape the consultation options as outlined in the Consultation document (details available upon request from the Consultation Office, Raebarn House, Waterlooville, PO7 7GP). This work provided the foundations for the formal consultation with a series of return visits to ten local service user groups such as SureStart and children's centres, the Parents' Network in Fareham Western Wards and National Childbirth Trust Groups this time to ask local people about the specific options for change.
To ensure a wider cross section of people had an opportunity to hear about the proposals and to share their ideas, suggestions and concerns, 13 drop-in events and market stalls were organised and two formal public meetings were held. These events were widely advertised in the local press, in TV and radio interviews, at GP surgeries, local libraries and Post Offices, via information from midwives and in posters in each of the existing birth centres. Trust and PCT staff were available for the public to speak with at each venue and colourful `story boards' gave a visual picture of the current situation and of the proposals.
There were also opportunities for staff to influence and shape the proposals at 13 informal presentations and roadshows (a summary of staff feedback can be found at Appendix 2). The programme of events is summarised below (a full record of all informing and engagement activity is available on request from the Consultation Office, Raebarn House, Waterlooville, PO7 7GP).
Ways to have a say |
Petersf'd & Liss |
Bordon & Alton |
F'ham East |
Whiteley & Western Wards |
Gosport & Lee on Solent |
Havant W'ville & Hayling |
Emsw'th & West Sussex |
St Mary's Hospital/Mary Rose Birth centre |
Total Number |
Drop-In Event |
_ |
_ |
_ |
_ |
_ |
8 | |||
Market Stall/ Shopping Centre |
_ |
_ |
_ |
_ |
5 | ||||
Informal Presentation Service Users |
_ |
_ |
_ |
_ |
_ |
_ |
_ |
10 | |
Public Meeting |
_ (set up by Save the Grange) |
_ |
2 | ||||||
Formal Presentation Stakeholders |
_ |
_ |
_ |
4 | |||||
Staff Road Show |
_ |
_ |
_ |
_ |
_ |
9 | |||
Informal Pres'tion Staff |
_ |
_ |
_ |
_ |
_ |
9 |
At all presentations and events comment sheets and freepost envelopes were provided for feedback together with information about other methods of giving feedback e.g. via the dedicated telephone line, via email, in writing and via the Trust web site. In total 640 feedback forms, 13 letters and 31 emails were received from members of the public and 98 feedback forms were received from staff (details of staff comments can be found at Appendix 2).
3.5 Feedback on the consultation process
The project team has been keen to demonstrate that the process has been open and transparent with the public and key stakeholders. Therefore it has taken the decision to have all the feedback independently analysed. This is a course of action recommended by the Independent Reconfiguration Panel who, if the Trusts were challenged over its approach to the consultation, could be making judgements and advising the Secretary of State with regard to the process and proposals. A member of the Patient & Public Involvement Forum independently verified the feedback on November 9, 2007. Furthermore, as part of their role the Patient & Public Involvement Forum visited one of the birth centre facilities and talked to staff, women and their families.
4. What local people, staff and stakeholders have said
Throughout the formal consultation everyone was encouraged to tell us what they thought about the proposals and to state a preference for one of the consultation options. Details of the preferences of staff and public for each option can be found at Appendix 4.
The full record of comments received is available on request from the Consultation Office, Raebarn House, Waterlooville, PO7 7GP, but a summary of the key themes from local communities, clinicians, staff and key stakeholders is set out below.
4.1 Community and stakeholder feedback
You told us ..... |
We listened |
About the Model of Care at Midwife Led Birth Centres · There must be a 24 hour midwifery presence · The option of post natal stays o Stays should be longer than one night for those that need it (recuperation and support with breast feeding and parenting skills). This could include the option of transferring from hospital to a birth centre in order to be closer to family and overcome transport issues (especially Petersfield and Gosport). There should also be the option to transfer to birth centre after Caesarean Section o Post natal stays make birth centres more attractive birth place choice · Extending the model of care o Birth Centres could become advice drop-in resource where opportunity to interact with professionals, NCT volunteers and other parents. WRVS could provide drinks to encourage socialising o Run ante natal and post natal appointments, and parenting courses at similar times to encourage more interaction between expectant mothers and existing mothers (source of advice & reassurance) o Antenatal classes for all mothers, even those having second, third, fourth child - still would benefit/ get reassurance · Paying for extras o Would like option of bedside telephone and television o Fresh fruit o Some women willing to pay for longer post natal stays |
· This was also a strong message during the pre-consultation phase. Hampshire PCT responded by making 24 hour midwifery care central to all consultation options. Portsmouth Hospitals NHS Trust welcomed and fully supported this decision · Within Portsmouth Hospitals NHS Trust (PHT) women have the option of up to 48 hours stay in any post natal facility. Women are able to stay longer than this where clinical need dictates. The vast majority of women now choose to stay for less than 48 hours · PHT recognises this important factor in influencing where women choose to give birth · The Implementation Group will explore ways of taking these ideas forward · The ongoing Implementation Group will explore ways of taking these ideas forward · The ongoing Implementation Group will explore ways of taking forward these ideas · This service should be available once services move to the new PFI hospital in Cosham · Service users can already order fresh fruit from existing menu · Portsmouth Hospitals are willing to consider the expansion of amenity beds as long as this does not impact on the clinical needs of other women |
Ongoing Concerns · Nuchal and anomaly scanning not yet available to all women - other areas provide and this means other services are chosen over Portsmouth Hospitals · Need adequate timeframe for remaining birth centres to prove sustainable - three years suggested by members of the public and key stakeholders (Portsmouth & SE Hampshire MSLC, Save the Grange/ NCT, Fareham Borough Council) · What marketing is going to be undertaken to increase use of birth centres from within & outside traditional catchment areas? · Impact of any changes at St Richard's Hospital, Chichester · Capacity. Is the number of beds sufficient? · Will staffing issues threaten closure again? · When will the changes be implemented? · Existing Queen Alexandra Hospital perceived as `sub standard' and `unclean' by a few local people. Concerned that moving maternity services to Cosham site will have impact on standards/ infection risks |
· All neighbouring NHS Trusts provide this screening to all women. Hampshire PCT and PHT recognise this is a major factor why women choose not to have their babies in PHT services. Portsmouth Hospitals NHS Trust already provide nuchal screening to women 32 years and over, and are continuing to work towards as earlier an implementation date as possible for all women · Both Hampshire PCT and PHT are committed to making the remaining birth centres sustainable. Partnership with local stakeholders will be central to the process, and will be steered by the Implementation Group. Key priorities for action will be jointly agreed and monitored. Regular reviews will enable proactive measures to be taken to overcome difficulties. · HPCT and PHT recognise the need to give the selected birth centres time to become sustainable - most notably the new model of service proposed for the Grange in Petersfield (in the event that the Board supports Option 1). Having made a decision, the PCT will be absolutely committed to making the new proposals work and will give a commitment to maintain the agreed model of care for a period of two years from the commencement of the service (the period advocated by the Hampshire Overview and Scrutiny Committee). However, this commitment cannot be absolute, as the PCT must always place the birth choices of mothers first and must therefore ensure it has the flexibility to respond to this if it is required. · PHT has established a Divisional Marketing Group to take this work forward, the work of this Group will be reported to the Implementation Group. Ongoing engagement with stakeholders, communities and staff will support the process. · PHT is confident that capacity within maternity services is more than adequate to deal with possible increases in demand as a result of changes to maternity services in West Sussex. However, the PCT recognises that there will always be changes in demand for services. So section 5.6 below recommends that the Board gives a commitment to keep the viability and sustainability of maternity service provision under review in light of changing birth rates and in the event that proposals in West Sussex increase the demand for services. · Hampshire PCT's contract with PHT stipulates that staffing levels should meet national standards. PHT's New Ways of Working Group is engaging all maternity service staff in developing sustainable staffing structures. PHT are currently developing a business case to support implementation of the chosen option . · PHT is working towards an April 2008 implementation · We take a pride in the cleanliness of St Mary's Hospital site and expect the same standards of cleanliness once services move to the new PFI hospital in the summer of 2009. |
Views about the co-located unit · Very useful for those women that want to have a midwife led birth but with the reassurance of medical assistance close by |
· We recognise this and prefer option 1 which retains the co-located unit. |
Birth place choice making · Information: Local people want to be better informed about all the options, so they can make choices in partnership with health care professionals · Range of influencing factors identified by parents o Where gave birth previously o Personal positive or negative experience of using a service o The positive or negative stories of other women o Where relatives live o Distance o Previous medical needs |
· PHT is developing new leaflets in partnership with service user groups, which will be used to promote the full range of options post consultation decision · The implementation Group will be using this feedback to shape and improve local maternity services into the future |
Strong support for local midwife Led services · Value homely, relaxed atmosphere at stand alone midwife led birth centres - great to socialise with other mums in day/ dining room · Value more one-to-one support (for example, with breast feeding) · Local service particularly important for people without a car · Encourage more people to give birth at home - More resources for home births |
· The implementation Group will be using all this feedback to shape and improve local maternity services into the future |
Locality specific themes Petersfield & Liss · Keep the Grange as 20 miles to any of the alternative services and serves outlying rural areas · Feedback highlights that birth place choices in this locality are home, Grange or main unit/ hospital setting. Little mention of co-located unit. Bordon, Alton, Liphook · Feedback highlights that birth place choices in this locality are predominantly hospital (Basingstoke, Frimley, Chichester & Portsmouth) Waterlooville & Havant · Highest number of responses in favour of Option 4 (close Blake Birth Centre, Gosport) · Many use St Richard's Hospital - Some would choose Grange if 24 hours, women would seriously consider services at new hospital in Cosham. Emsworth Fareham · Local people expressed concern about the lack of a local birth centre. They were worried that accessing either Blake or the co-located unit could be difficult for Fareham women. · People felt that the rising birth rate in Fareham meant that it should have a local birth centre. · Women wanted continuity of care between their community midwife and their birthplace choice Western Wards · There were particular concerns about the potential for a rising birth rate in these wards due to new housing developments. · Travel concerns - distance to a birth centre from this area was a concern Gosport · Travel concerns - Distance to Portsmouth, plus getting in and out of Gosport particularly at peak times very difficult - must keep Blake open · Strong support for keeping Blake - highly valued local resource - particularly important for local people on low incomes - need increasing with new housing developments in Gosport & Lee on Solent · Feedback highlights women in this locality tend to access St Mary's Hospital or Blake Birth Centre. A few have used Blackbrook in the past |
· The preferred option retains and develops The Grange as a local birth centre staffed 24/7 by midwives · The preferred option retains and develops The Grange as a local birth centre staffed 24/7 by midwives, this provides an alternative choice for these localities. · The preferred option retains and develops The Grange as a local birth centre staffed 24/7 by midwives, together with the co-located unit, this provides an alternative choice for these localities. · Section 5.6 recommends that the Board give a commitment to regularly review Fareham and Western ward birth rates and reconsider the development of a birth centre within Wave 2 of the Fareham Community Hospital in light of the demand and the experience of women in accessing other birth place choices. · The Implementation group will work with service users in this locality to take forward an acceptable model for local women · Section 5.6 recommends that the Board give a commitment to regularly review Fareham and Western ward birth rates and reconsider the development of a birth centre within Wave 2 of the Fareham Community Hospital in light of the demand and the experience of women in accessing other birth place choices · The recommended option retains Blake |
As well as views and comment on issues specific to the consultation, many local people also shared their individual stories and experiences of using maternity services across Hampshire, West Sussex and Surrey. This information will be shared with the relevant maternity service provider Trusts and Foundation Trusts, so that services can be improved or commended in line with what was said.
5. Recommendations
In reaching a decision around future service provision the Board needs to take into account the four key criteria set out in section 2.3, together with the issues set out below.
5.1 Taking local expectations into account
The Board is asked to note that there has been an expectation from residents of Fareham, dating back to the former Fareham and Gosport PCT consultation on the Future of Local Health Services in Fareham and Gosport in December 2004, that a birth centre would be provided at the new Fareham Community Hospital. In addition discussions with local stakeholders on the temporary closure of Blackbrook Birthing Unit in Fareham were predicated on the reprovision of services within the new Fareham Community Hospital scheduled for development in 2010.
However, there has also been a recognition from all of the stakeholders involved in this consultation and pre-consultation debate that the development of an appropriate and sustainable model of maternity services for south east Hampshire is long overdue, having been hindered in the past by an overly localised approach to planning and lack of a clear and sustainable vision.
Throughout this consultation Hampshire PCT and Portsmouth Hospitals NHS Trust have sought to build up a model of service by understanding the needs and expectations of local mothers, and then to design a set of proposals that meet these needs and expectations for the majority of the local population.
Although the outcome of this consultation is potentially different to the outcome of earlier consultations, the Board is asked to note the integrity of both the consultation process and the models of care proposed. The fact that 30% of feedback forms from service users in the Fareham area indicated their support for the preferred option is testament to this.
In order to sustain three birth centres providing midwife-led care, we estimate that an absolute minimum of 250 births a year at each centre is required. If usage drops below 250 births a year, the PCT and Portsmouth Hospitals NHS Trust will need to reconsider whether the units are sustainable and whether to redeploy staff to support other services that women are choosing to use.
In addition the Board should take into consideration that:
· We need a safe, sustainable, high quality, cost effective service
· Years of uncertainty means women are not choosing to use the facilities we are providing in our stand-alone birth centres
· More women are choosing to use the co-located birth centre and the consultant-led unit at St Mary's Hospital, which will transfer to Queen Alexandra Hospital in 2009
· Costs for each option vary - option one being the most affordable, followed by options 2 and 4, with option 3 incurring the highest costs (detailed costs are set out in Appendix 1)
· There would be no reduction in services, as antenatal, homebirth and postnatal services would continue to be provided locally. Some women may need to travel further if they choose the option of a stand-alone birth centre.
· The birth rate continues to rise in the Fareham area.
5. 2 Option 1
Provide three midwife-led birth centres in:
1. Petersfield - Grange Birth Centre = 8 beds
2. Gosport - Blake Birth Centre = 11 beds
3. The co-located service in Portsmouth (currently at St Mary's Hospital, moving to the new Queen Alexandra Hospital in Cosham in 2009) = 12 beds (2006) but 11 beds (from 2009)
Recommendation
The Board is recommended to agree this option. However given concerns raised during the consultation regarding the future provision of birth centres beds in the Fareham area to support an increasing birth rate, it is recommended that the PCT gives a commitment to review the need for birth centre beds in Wave 2 of the Fareham Community Hospital development in 2009.
The reasons for recommending this option are:
· It ensures that the purpose built Grange and Blake Birth Centres are retained in areas that are more geographically isolated, in line with our commitment to ensure access to a range of choices and to ensuring that we maximise bed usage.
· It retains use of the co-located unit which is the most heavily used of the Birth Centres in south east Hampshire also meeting our commitment to choice and access and to maximising bed usage.
· It means £1m investment would not be required to update Blackbrook, making this the most affordable and sustainable option.
· Fareham itself is in a geographically advantageous position ensuring women in the area still have good choice and access to other services.
· The development of the Fareham Community Hospital allows for the future expansion of maternity services in the area should birth rates exceed predicted levels, ensuring that we retain flexibility over choice and access into the future. It is recommended that the Board regularly review birth rates and demand for services to ensure the configuration meets local needs (see section 5.6 below)
· It retains Blake and the co-located birth centre which are the best used of the birth centres.
· In line with our commitment to listen to the views of local women this option retains Blake and the co-located birth centre which are valued by local women and also offers a sustainable future for the Grange which local women have told us they would support.
· 78.9% of the 640 feedback forms received from member of the public supported this option. Support was not as strong in the Fareham area however, where 30% of feedback forms from service users in the Fareham area favoured this option, with 37% supporting option 3, 21% opting for option 2 and 11% option 4.
· 56.1% of the feedback forms received from staff supported this option
5.3 Option 2
Provide the three midwife-led birth centres in:
1. Gosport - Blake Birth Centre = 11 beds
2. Fareham - this would mean upgrading Blackbrook = 10 beds
3. The co-located service in Portsmouth (currently at St Mary's Hospital, moving to the new Queen Alexandra Hospital in Cosham in 2009) = currently 12 beds (2006), 11 beds (from 2009).
Recommendation
This option is not recommended as:
· It is not in line with our commitment to offer choice and good access to services because removing provision from Petersfield restricts choice and forces women to consider alternatives outside the area due to the town's location.
· It incurs greater costs to the local NHS which need to be funded from within existing resources, meaning it does not meet criteria for affordability and sustainability.
· The closure of the Grange would lead to the loss of a modern, maternity unit without releasing any significant money that could be reinvested (this is because the unit is located within Petersfield Community Hospital).
· We have given a commitment to listen to the views of local women and there is a high level of support for a birth centre at the Grange staffed by midwives 24/7.
· It creates two stand-alone birth centres relatively close to one another which will not allow us to maximise bed usage.
· Only 5.3% of the 640 feedback forms received from members of the public were in favour of this option.
· Only 7.1% of the 98 feedback forms received from staff were in favour of this option
5.4 Option 3
Provide the three midwife led birth centres in:
1. Petersfield - Grange Birth Centre = 8 beds
2. Gosport - Blake Birth Centre = 11 beds
3. Fareham - this would mean upgrading Blackbrook to provide 10 beds
Recommendation
We do not favour this option because:
· Removing the co-located unit is not in line with our commitment to ensuring women have choice and good access to services.
· The co-located unit offers reasonable access to all parts of south east Hampshire, access which will (in most cases) improve after 2009.
· The co-located offers a unique choice for local women who say that they find the option of a midwife-led birth centre next door to the main consultant-led birth unit very reassuring. Removing this option would be contrary to local views.
· It incurs the greatest costs to the PCT which need to be funded from within existing resources, meaning it does not meet criteria for affordability and sustainability.
· The midwife-led unit located alongside the main consultant-led unit is one of the most well-used birth centres. This option is therefore less likely to increase bed usage.
· Only 10.2% of the 640 feedback forms received from members of the public supported this option.
· A higher proportion (33.7%) of the 98 feedback forms received from staff were in favour of this option
5.5 Option 4
Provide the three midwife-led birth centres in:
1. Petersfield - Grange Birth Centre = 8 beds
2. Fareham - this would mean upgrading Blackbrook = 10 beds
3. The co-located service in Portsmouth (currently at St Mary's Hospital, moving to the new Queen Alexandra Hospital in Cosham in 2009) = currently 12 beds (2006), 11 beds (from 2009)
Recommendation
We do not favour this option because:
· The geographical location and demographics of the Gosport area make it difficult for women to access other services and closure of the centre would present a number clinical safety issues. This option is therefore not in keeping with our commitment to giving women choice and access.
· It incurs greater costs to the PCT which need to be funded from within existing resources, meaning it does not meet criteria for affordability and sustainability.
· The closure of Blake would also lead to the loss of a modern, maternity unit without releasing any significant money that could be reinvested (this is because the unit is located within Gosport War Memorial Hospital).
· Blake is also highly valued by local women and it would be contrary to local views to not to provide this option.
· Blake has the highest occupancy rates for the stand-alone birth centres, therefore removing it would not help to maximise bed usage
· Only 5.6% of the 640 feedback forms received from members of the public were in favour of this option.
· Only 3.1% of the 98 feedback forms received from staff and clinicians were in favour of this option
5.6 Decision required
The Board is therefore recommended to agree option one with a commitment to:
· Regularly review birth rates and demand for services in light of changes locally and in neighbouring areas to ensure the configuration of birth centres is best placed to meet local needs. If there are significant changes in birth rates or demand the PCT will reconsider the development of a birth centre within Wave 2 of the Fareham Community Hospital taking into account the experience of local women in accessing other birth place choices
· Work collaboratively with Portsmouth Hospitals NHS Trust, partner organisations and local women to raise the profile of local birth centres and ensure that local women have the choice of a birth centre birth
· Establish an Implementation Group with service user, commissioner and provider representation to oversee the implementation of the recommended option and to ensure that patient experience issues raised during the consultation such screening, the service model and improved information are actively addressed.
6. Next steps
An Implementation Group will be established and meet for the first time in December 2007. The Group will be tasked with taking forward the recommendations above and will report progress regularly to the Boards of Hampshire PCT and Portsmouth Hospitals NHS Trust, and the South East Hampshire Maternity Services Liaison Committee.
Appendix 1: Cost breakdown for each option.
Option 1 | |
Trained midwives |
£530,000 |
Healthcare support workers (maternity care assistants) |
£255,000 |
Overheads |
£598,000 |
Loss of rental income |
£0 |
TOTAL |
£1,383,000 |
Option 2 | |
Trained midwives |
£530,000 |
Healthcare support workers (maternity care assistants) |
£255,000 |
Overheads |
£598,000 |
Loss of rental income |
£240,000 |
TOTAL |
£1,623,000 |
Option 3 | |
Trained midwives |
£740,000 |
Healthcare support workers (maternity care assistants) |
£356,000 |
Overheads |
£846,000 |
Loss of rental income |
£0 |
TOTAL |
£1,942,000 |
Option 4 | |
Trained midwives |
£530,000 |
Healthcare support workers (maternity care assistants) |
£255,000 |
Overheads |
£598,000 |
Loss of rental income |
£240,000 |
TOTAL |
£1,623,000 |
Appendix 2: Themes from Staff Engagement
(Staff views have been collated from returned feedback forms, discussions at Staff Road Show events, and other meetings with staff)
What Staff Said |
How We have Listened |
Feedback from staff employed by Portsmouth Hospitals NHS Trust Includes Midwives, Maternity Care Assistants (MCA's) and Doctors | |
Midwife Led Beds at Fareham Community Hospital · Staff concerned that beds needed in the Fareham area (including at planned Fareham Community Hospital in Sarisbury Green) due to predicted population rise · Majority of staff responses recognise that renovating Blackbrook is not a good use of public money · As Blackbrook close to the co-located unit if moves to Cosham, a better option would be a fourth birth centre in Sarisbury Green |
· Section 5.6 recommends that the Board give a commitment to regularly review Fareham and Western ward birth rates and reconsider the development of a birth centre within Wave 2 of the Fareham Community Hospital in light of the demand and the experience of women in accessing other birth place choices. |
Staffing Levels · Many staff commented on the need for more midwives and maternity care assistants in order to implement the chosen option |
· PHT are currently developing a business case to support implementation of the chosen option · As part of its contract with Portsmouth Hospitals NHS Trust Hampshire PCT expects the Trust to be compliant with national standards for staffing levels. |
Co-located Birth Centre · Concerns raised about the size of the space set aside for the co-located unit if it moves to Cosham as part of redevelopment of Queen Alexandra Hospital. Limited space has implications for the model of care that can be provided · Several staff across maternity services have expressed a preference for stand alone birth centres over co-located model · The co-located unit was considered essential by a doctor who responded |
· Portsmouth Hospitals NHS Trust are currently looking at different ways of addressing this in partnership with maternity service staff · 700 women a year currently have their babies at the co-located unit (Mary Rose Birth Centre). This is twice the number of births at Blake Birth Centre. Also during the consultation process women (particularly first time mothers) told us that they like the reassurance of proximity to the main unit this option offers. The preferred option of Hampshire Primary Care Trust is to maintain this choice for local women |
Staffing Model · Most midwives said there is a need for all birth centres to be staffed 24 hours a day by midwives · Some staff have stated a preference for retaining core staff in the birth centres (this would mean continuation of existing situation where in some areas the birth centre and community midwifery teams are separate teams) |
· This was also a strong message from local people, especially during the pre-consultation phase. Hampshire PCT responded by making 24 midwifery care central to all the public consultation options. Portsmouth Hospitals NHS Trust welcomed and fully supported this decision. · Portsmouth Hospitals NHS Trust, through the News Ways of Working Group, are developing and agreeing new staffing models. It is proposed that there will be a move away from core staff in stand alone birth centres to a model of integrated staffing |
Telephone Calls · Many maternity service staff mentioned volume of phone calls to birth centres and the impact this has on quality of care - some solutions suggested at Staff Road Show events |
· PHT have have established a working group to develop solutions to this issue building on the ideas suggested by staff. The group will work in partnership with the PCT where relevant. Progress will be monitored by the Implementation Group. |
Ante Natal Screening · Importance of having full screening services in line with neighbouring NHS Trusts highlighted if going to attract women to local services |
· Portsmouth Hospitals NHS Trust already provide nuchal screening to women 32 years and over, and are continuing to work towards as earlier an implementation date as possible for all women. Hampshire Primary Care Trust will be holding Portsmouth Hospitals Trust to account over delivery of screening for all women via the Maternity Services Implementation Group. |
Locality Specific Views · Petersfield, Havant, Waterlooville & Cosham: (Includes community staff who also cover the Grange) o Staff in this locality believed that reopening Grange with 24 hour midwifery presence will attract women back from Chichester, Basingstoke, Winchester & Guildford maternity services o Grange important to retain as helps secure relationship between urban and rural districts · Fareham & Gosport: (Blake Birth Centre staff, Fareham & Gosport Community Staff) o Staff in this locality believed that maternity beds at Coldeast would attract women back from Winchester and Southampton |
· Hampshire PCT's preferred option is to re-open the Grange with 24 hour midwife presence. Both the PCT and Portsmouth Hospitals recognise the importance of this to making the remaining birth centres sustainable. · Section 5.6 recommends that the Board give a commitment to regularly review Fareham and Western ward birth rates and reconsider the development of a birth centre within Wave 2 of the Fareham Community Hospital in light of the demand and the experience of women in accessing other birth place choices. |
Views from Health Visitors (Employed by Hampshire Primary Care Trust) | |
· It is important to keep smaller more personal centres running · Retaining a birth centre in Fareham would be accessible to residents from Gosport. In addition the PCT could provide services to mothers living in Whiteley and the Western Wards who currently opt for delivery in Southampton and Winchester. The Gosport traffic is an ongoing difficulty whether clients from Fareham travel to Gosport or Gosport clients travel to Fareham. I feel a centre in Fareham is generally more accessible for the population west of Cosham (Option 4 preferred) |
|
Appendix 3: Themes from Key Stakeholder Engagement
What Stakeholders Said |
Maternity Service Liaison Committee (MSLC) |
Portsmouth & South East Hampshire MSLC · Support Option 1 as allows greatest potential of choice for women, and makes the best use of resources that are available · Concerns: o Whether the building plans at Queen Alexandra support a co-located unit as proposed layout will not allow for a marked differentiation in the culture of care between the main and co-located areas. The MSLC considers the move to QA an opportunity for a change in the standard culture and environment of birth, and asks to be kept informed, as a minimum, of the Trusts plans for a normal birth environment. o The MSLC would like to ask that further consideration is given to the time frame being given to the birth centres to assess their viability. Questions have been raised as to whether an 18 month period is long enough. The MSLC believes that it will be necessary to rebuild confidence in the birth centres and we are suggesting a time frame of 3 years. This will allow a period of time before and after maternity services move from the St Mary's site to Q.A. o The MSLC wish to express their strong opinion that, in the light of the demographic projections given, the Fareham situation must be reviewed in a timely manner with a view to providing a midwife led unit for Fareham and District as soon as practical. o Concerns have been raised with regard to the timing of the consultation in relation to proposals and consultation process being undertaken by West Sussex and Brighton and Hove City PCT's. Decisions made here could impact on and affect women from the Hampshire and Portsmouth City PCT areas. What would be the impact on our services if St Richards's hospital no longer provided maternity provision. Would this lead to a greater demand on the services in our area and is there enough capacity to meet any additional demand. o If there is a commitment to open the birth centres 24 hours a day 7 days a week. Then they need to remain open. If there are staff shortages in the main unit, that this must not impact on the birth centres. In the past this has lead to the intermittent closure of various birth centres. If this happens again the confidence in the birth centres will be lost and women may not choose to use them. |
Practice Based Commissioning (PbC) Clusters |
Gosport PbC Cluster · Support Option 1. Presentation made at cluster meeting and options and issues discussed. Individual practices then responded. All respondents supported Option 1. East Hampshire PbC Consortium · In favour of Option 1 based on the need for local services, a comprehensive service offering a full range of care, and a twenty-four hour service led by midwives · Consortium would want to see: o Definite commitment to Grange opening fully this financial year o Preferably a firm start date as mothers will hesitate to book for a delivery in a unit that may not open in time for their due date o A full complement of trained staff with adequate contingency cover o A service to include antenatal care and post natal care in the surgery, at home or in the unit, 24 hour delivery suite for normal deliveries, postnatal inpatient care, local parent craft and active birth classes, o A full screening service including nuchal fold testing and anomaly scans for all mothers at the peripheral units, not limited to the central department o A local team offering continuity of care o Full liaison with GP's in the area for proper communication to avoid mishaps o Ability for mothers to opt for home delivery if appropriate o Co-operation with community midwives across East Hampshire some of whom are employed by different trusts. o This is to avoid the current inability of mothers to remain registered with the same practice if they chose a home delivery or postnatal care at home in a geographic area not covered by the community midwife o There are currently a high number of home births and normal deliveries from East Hampshire. As a group we refer to Basingstoke, Frimley, Royal Surrey in Guildford, St Richards in Chichester and Winchester as well as Portsmouth. This is based on patient choice. In order for the Grange to remain sustainable, we would expect to have a really excellent service there so that we feel able to market this as a viable alternative. |
County, Borough & District Councils |
Fareham Borough Council · Executive members decided to support Option 3 (Blake at Gosport, The Grange at Petersfield and Blackbrook at Fareham) with the amendment that Blackbrook is closed and replaced with a birth centre at the new Fareham Community Hospital. · Acknowledged that there is a need to make changes to the provision of maternity services in South East Hampshire. The costs of provision need to be realistic, given the budgetary constraints faced by the Primary Care Trust and it is important to recognise that underused facilities are not sustainable. However, they also recognised that local women should have easy access to modern facilities and a choice of birthing options. · The low occupancy figures for Blackbrook were acknowledged but Councillors felt that the data should be treated with caution. For example, there is no evidence to demonstrate that the low figures were due to a lack of interest (i.e. parental choice) or the fact that the facility is outdated and has been closed over recent years. · References are made in the consultation document to the future provision of a Community Hospital in Fareham, by 2010, but Councillors expressed a concern that there are still no guarantees that this facility will be built. It is believed that the outline plans for the Community Hospital actually include provision for 12 maternity beds in the future and construction is supposed to start in late 2008. However, a final decision still needs to be taken as to whether the project will go ahead. This uncertainty makes it very difficult to have an informed debate on future health provision in the Borough. · Given the increasing pressures on the local traffic infrastructure, the most sustainable option is for the Borough Council to support the retention of a birth centre within the Borough. However, it is recognised that the refurbishment of Blackbrook is not really a viable option. The preference would be for a new "stand alone" birth centre to be built as part of the new Fareham Community Hospital. Such an approach would provide a more accessible birth centre for women living in the Borough of Fareham. It would also minimise construction costs as it would be built as part of a larger scheme. · The main concern for the Borough Council would be that yet another NHS facility in the Borough could be closed down when all evidence points to a significant population growth in the area over the next 10 -20 years. Your consultation document recognises that Fareham's predicted birth rate is expected to increase by 14% from 2005 to 2026, whereas all other areas will see a decline in birth rates. The consultation document appears to indicate that the growth in Fareham will be offset by significant falls (and therefore bed capacity) in other areas. Realistically, this approach is not sustainable as Fareham residents are not going to travel to Petersfield and, given the current traffic problems, are also unlikely to use the Gosport facility. · The document goes on to suggest that should birth rates in Fareham rise beyond the current projected levels there will be an opportunity to reassess current provision and seek to expand services in the Fareham area, by making use of the proposed Fareham Community Hospital, due to open in 2010. Fareham Borough Council would wish to see such an arrangement in place sooner rather than later. · It is also a matter of some concern that Portsmouth could end up with three birth centres (i.e. the main Maternity unit and a co-located unit at Queen Alexandra Hospital and also a new unit to be provided by Portsmouth Primary Care Trust at St Mary's Hospital), whilst Fareham would have no birth centre within the Borough · Hampshire Action Team (HAT) for East Hampshire · Supports Option 1. HAT members unanimous in their views that most important factor for residents of East Hampshire is that the Grange Birth Centre at Petersfield remains open and provides midwifery provision 24 hours a day, 7 days a week, 365 days a year · The HAT for East Hampshire would also be supportive of options 3 and 4 which include the Grange as one of the 3 remaining birth centres Gosport Borough Council · Endorses implementation of Option 1 with reservations listed as: o We need to be reassured that due consideration been given to projected 80 - 120,000 new homes that are to be provided in the region under the South East Plan. That future provision will have been fully catered for and that existing service levels will be flexible enough to react in planned way o That extension of maternity services at Fareham Community Hospital be provided within the planned Community Hospital build o Gratifying that importance of staffing Blake 24 hours a day with fully qualified midwives is recognised, however under Option 1, there will be no facility at Fareham. o Under Option 1 there will be no facility at Fareham. Blackbrook would remain closed and would be available for disposal. This would impact on the ability of Blake in Gosport to cope with cases from Fareham and outlying districts. The assurances that bed numbers and staffing levels ara sufficient and that the projections do incorporate these factors are noted o The difficulties of access to and from Gosport are well documented and to date there is no prospect of any significant improvements to traffic flow. o With the ongoing reconfiguration of services in West Sussex, the Council feels constrained to register concerns that movement of patients may occur across borders in search of services that have been lost in their area. Assurance will be sought that there is sufficient capacity available within the proposed options to cope with such an eventuality o From a Gosport perspective Option 1 appears to provide an appropriate and sustainable level of service whilst having sufficient capacity for women from the Fareham area. The Gosport Healthy Alliance (Health & Wellbeing Sub-Group of the Gosport Local Strategic Partnership) · Supports Option 1 as preferred option · Option 2 or 3 would also be supported as providing continuing maternity services within Gosport. Option 4 is not supported. Havant Borough Council · The Executive of Havant Borough Council unanimously supported Option 1. |
Views of Representative Bodies |
Royal College of Midwives (RCM) · The RCM notes that any re-configuration of the services in South East Hampshire should meet the recommendations of "Maternity Matters" and "Safer Childbirth" documents. · The RCM is mindful that whatever option is chosen, a period of stability and commitment from the Portsmouth Hospitals NHS Trust and Hampshire Primary Care Trust (PCT) is required to make the birthing centres a success. Continual closures undermine both the staff trying to deliver quality care and the women and the families they care for. This will take time to rebuild and a strong marketing strategy will need to be developed. · The RCM welcomes Hampshire PCT's commitment to have midwives staffing the birth centres 24 hours a day, 7 days a week. However, we are unclear whether this will involve having core staff on the birthing centres. The RCM is also unclear on what staffing ratios will be applied. · The RCM also expects that any changes to midwives' working practices following the result of this consultation should and will be fully consulted and negotiated with the RCM and its members. · The RCM notes that maternity beds have been lost across the Trust. If Option 1 is chosen, further beds will be lost in Fareham. The RCM recommends that more beds will be required and not less. This will be particularly urgent for the Fareham area. How will this be addressed? · The RCM is also concerned at the geography and location of the new co-located unit at the Queen Alexandra. There is the potential for this unit to simply become an overflow ward for delivery suite. UNISON · Support for Option 1 as does not involve cost of upgrading Blackbrook and Cosham accessible from Fareham |
Health Overview & Scrutiny Committees (HOSC) |
Hampshire Overview and Scrutiny Committee · The HOSC accepted that there needs to be a threshold below which units will not be viable, but asked that the PCT was flexible in the first 18 months to two years of operation to maximise opportunities for women to become with the services available. · The Committee considered that further testing needed to be done to ensure that women who currently use St Richards can be accommodated should services from this site be relocated. There were also concerns that this increase in demand could disadvantage women from other areas. · Supported the 24 hour midwife staffed model. · The Committee expressed concern about that the rising birth rate in Fareham and the populations on the western boundary of Fareham Borough had not been fully taken into account. · The Committee stated that an absolute assurance had been given by a predecessor PCT to develop a birth centre at the Fareham Community Hospital. The Committee sought assurance that this commitment would be honoured by Hampshire PCT. Portsmouth Health Overview & Scrutiny Panel · Whilst the Panel appreciate that elements of the proposals may have a greater impact on services and populations outside the city's boundaries, the Panel retains an interest in ensuring that Portsmouth women continue to exercise a full range of birth choices in the future. Therefore whilst the Panel is pleased that Portsmouth City PCT has signalled its intention to provide a midwife-led stand alone birth centre on Portsea Island after 2009, Members recognise that many expectant mothers in the city will still wish to choose a midwife-led co-located unit that has immediate access to the facilities and medical procedures in the main obstetric unit should that be required. As such the Panel has expressed its firm support for the continued provision of a co-located unit at Queen Alexandra Hospital after 2009. · Panel also expressed support for Hampshire PCT decision to staff birth centres in south east Hampshire with fully qualified midwives 24 hours a day, 7 days a week |
Response form
This electronic form has been produced for people who wish to respond to `Have your say - Consultation on the regulations for LINks' and is a copy of the response form contained within the consultation document.
To download a copy of the `Have your say' document, please visit www.dh.gov.uk/patientpublicinvolvement. Responses to the consultation on LINk regulations should be returned by Friday, 21 December 2007.
Responder details
Name:
Organisation:
Contact details
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Email:
Questions relating to `Responding to requests for information made by a LINk' (see page 10)
_ Do you think that services-providers should have duties to provide information to LINks that go beyond the obligations imposed in the FOI Act 2000? If so, what should they be and why are the duties needed?
We consider that it is appropriate to have this duty aligned with that relating to the FOI act. In particular, it is important that the LINk accesses available information before approaching either a services providers or an OSC.
Questions relating to `Responding to reports and recommendations made by a LINk' (see page 12)
_ Do you have any comments on these proposals?
It is essential that the reports and recommendations made by the LINk take account of the relevant evidence base and reflect the views of the population/service users NOT the views of the LINk. Equally, the focus of any reports must be on improving services. It may be appropriate to focus the report/recommendations in the context of the key areas identified in the Darzi interim review, i.e. fairness, responsiveness to need, effectiveness, safety.
There also needs to be clarity about the ultimate authority for making a decision. Local Authorities and NHS organisations do, on occasion, have to make difficult decisions that may not be popular with the public or some groups of service users. Often these can be focused on a facility/building rather than an actual service. Decisions need to be evidence based and transparent, with full consideration of a range of views from stakeholders; this does not mean that the recommendations of the LINk will always be met. There needs to be a clear point of closure on specific issues/decisions.
_ Is the timescale of responding within 20 days appropriate?
As long as it allows for there to be an interim response where complex issues need to be considered. Where the LINk is making a referral to a HOSC it should be required to demonstrate that it has exhausted the options for local action.
Questions relating to `Duty of services-providers to allow entry by LINks' (see page 16)
_ Do you have any comments on these proposals?
There needs to be a clear code of conduct for supporting this power that is understood by all. It is not clear if the LINk will be able to unannounced visits or if these should be arranged in advance. Equally there will be times where a visit may affect actual service delivery- this would not be acceptable.
The reasons for viewing a service need to be clear- i.e. not just because a LINk has an interest- any visit also needs to have some sort of report back stating what was viewed and how this informed the work/area of interest to the LINk in the context of its primary duties to secure the views of service uses/communities.
_ Are the premises that are exempted from the duty to allow entry appropriate?
Yes
_ Are there any further premises that should be exempted?
Any premises where people are vulnerable or may have challenges in expressing their preferences or wish for privacy. The regulations refer to children's services that cease at 18- this is not always the case with some supported past this date into their 20's. This needs to be recognised in the regulations
_ Do you feel the safeguards in place are proportionate? If not, why not? What do you think should be altered and why?
This needs to be tested. There may be times where the LINk is pursuing an issue for political or potentially vexatious reasons not associated with its primary duties- in these circumstances the right to view should be open to appeal or some sort. Equally the number of occasions on which a service can be viewed within a specific timescale needs to be considered.
Questions relating to `LINk referral to an overview and scrutiny committee' (see page 18)
_ Do you have any comments on these proposals?
The duties accorded the LINK are very specific in terms of their role getting people views on services. However they are not the only route through which this feedback will be sought. In making a referral they must be able to demonstrate that they are reflecting the views presented to them (and NOT their own) and that they have sought to initiate change with the appropriate service providers/commissioners as well as taking account of the relevant evidence base.
In the same spirit the OSC should be able to refer issues to the LINk if there are concerns about how a service is being delivered or a possible unmet need.
_ Is the timescale of responding within 20 days appropriate?
It is for the OSC to determine its own work programme and this needs to be clearly set out. Whilst the feedback from the LINk may inform and on occasion support this work. Complex or detailed responses may take more time to prepare and the emphasis needs to be on thoroughness rather than a somewhat arbitrary timescale
Where to return this form
Please return your consultation response to
PPI Team
Department of Health
502A Skipton House
80 London Road
London SE1 6LH
Or Fax: 020 7972 5643 Or Email: [email protected]