Meeting documents

To consider a report by the Transformation Programme Lead for the Adult and Community Services Forward Together Programme (attached).

The Committee received presentations by the Clinical Commissioning Group (CCG) and the NHS partners in response to the Dorset Health Scrutiny Committee’s request to make a referral to the Secretary of State (SoS) for Health in respect of the concerns about the Clinical Services Review at its meeting on 13 November 2017, and subsequent consideration of further information at the Joint Health Scrutiny Committee meeting on 12 December 2017. The remit of the referral was about the proposed reduction in the number of acute hospital beds, the reduction in Accident and Emergency services at Poole Hospital, concerns about travel times, confidence in the ambulance service data, and the lack of a clear Equality Impact Assessment or financial plan.

All concerns raised as part of the referral request related to the proposals in respect of the acute hospitals which included:

·         a major emergency hospital (MEH) at Bournemouth with 24/7 consultant led Accident & Emergency (A&E) Department;

·         a major planned hospital at Poole including an Urgent Care Centre 24/7; and,

·         Emergency and planned hospital at Dorchester with retention of A&E services.

Tim Goodson, Chief Officer for the Dorset CCG, also drew attention to his announcement earlier in the meeting on the intention to work to maintain a consultant-led maternity and overnight children’s service in Dorchester as part of a single maternity and paediatrics service for Dorset.

Three public questions and two public statements were received at the meeting under public participation.  The questions, answers and statements are attached as an annexure to these minutes.[APH1] 

Detailed presentations were received in relation to:

Ambulance Travel Times

The presentation focused on the assessment of the proposed changes in the CSR, which included population growth and service demand, and had taken into account the impact on travel times as a result.  The changes would see a transformation of service provision as a whole system plan, and would look to ensure people were taken to the right hospital at the right time which would save lives through the right care being provided at the right place, in addition to reducing the number of transfers between hospitals by ambulance.  Fewer patients who call 999 were taken to hospital these days (over half were treated on-scene) and, of those who were taken, only 1% were deemed to be life threatening cases.   85% of future ambulance journeys could be made in the same or less time than the existing arrangements.  From the remaining 15%, with particular reference to Purbeck, there was a spread of admissions to Dorchester, Bournemouth and further afield to other hospitals depending on the circumstances of the emergency which would see an increase in travel time, but these would be to the most appropriate hospital setting for the patient rather than the closest hospital.

In terms of ambulance waiting times to transfer patients to A&E, the pressure on services was a major concern of the NHS and proposed changes to Royal Bournemouth Hospital would include mitigation through the physical extension of the A&E service in a revised hospital design over the next 5 years. New road access to the Hospital from the A338 was raised, but it was clarified that the new road would be needed with or without the hospital changes. The plan would also evolve over time and would continually change and adapt moving forward. 

The ‘golden hour’ concept was discussed by members, and challenged by NHS professionals as the reality of population, dispersity and transport in Dorset did not make the concept realistic, and it also did not take account of the care provided in the ambulance and the start time of the hour being from the point of injury or trauma, where it was often not possible to arrive at hospital within an hour. 

The Chairman drew attention to the recommendation of the Joint Health Scrutiny Committee on 12 December 2017 to jointly scrutinise the capacity and performance of the ambulance service.  Further views were expressed by members which included the lack of funding available to resource the Ambulance Trust; concern over the funding of transport to rural-proof Dorset, including travel times without ambulance; and support for community based transport initiatives.

Integrated Transport

Following the concern raised above, clarification was given by the CCG that it was not their statutory responsibility to provide funding for integrated transport, but it was willing to be part of identifying solutions.  The CCG was already embedded in a process of joint working with the County Council to address rural isolation through a Pan-Dorset Transport Reference Group with health identified as a priority.  Investment in the non-emergency Patient Transport Scheme had also been increased from £3m to £5m through an integrated transport programme.

Matthew Piles, Service Director – Economy from Dorset County Council, provided an overview of the joint working to identify and use assets and knowledge to effectively facilitate travel planning and deploy community and local transport initiatives, including schemes which included opening school bus routes to the public.

Community Based Services

An extensive summary on the steps being taken to move community care closer to the home for patients was provided, which would lead to less patients needing to access acute care.  Support was voiced by a range of GPs from across the whole of Dorset in respect of primary care provision, which explained the background input of over 600 clinicians to the CSR, the history of integrated health and social care services.  A number of initiatives were outlined which included providing appropriate and timely care to enable people to stay at home; to avoid stays in hospital of more than 2 days; encouragement of school leavers and graduates to enter caring professions to support community care; relocation of diabetic support in Purbeck out of hospital setting; a Community Hub in Wareham as a template for other areas moving forward; a Community Services Reference Group in North Dorset; work with the Local Authority to improve domiciliary care; providing a focus on the wider determinants of public health; an Urgent Care Centre in Weymouth which prevented 30k of admissions to Dorset County Hospital (DCH); development of a frailty team including support for end of life care plans; development of GP access 7 days per week; enhanced intermediate care solutions (including a Community, Physical and Mental Health Hub in Bridport); and work beyond social care with recognition through local planning for key worker housing.  Sally O’Donnell, Locality Director Dorset HealthCare, reiterated the value of the integrated work which had already started, which is building the infra-structure ahead of the planned changes associated with the CSR.

The benefits of the CSR to the wider population were felt by the CCG, hospitals, the South West Ambulance Trust and GPs to far outweigh the increase in time taken to get to hospital in emergency situations. It was also felt that any delay in the progression of the CSR would create a real risk to patient care and to funding.

Members highlighted that the question of a referral to the SoS for Health was not a criticism of the professionalism of people working in health services.

Acute Hospital Services

Patricia Miller, Chief Executive Dorset County Hospital (DCH), emphasised the support from her Trust for the proposals and noted that there would not be enough money in the system without the changes.  DCH saw the retention of A&E and trauma services and the development of integrated community and primary care hubs as critical, and welcomed the announcement made by the CCG regarding the retention of maternity and paediatric services. The Chief Executive committed to making sure that any changes would deliver the best outcomes for Dorset residents.

Paul Miller, Director of Strategy Poole Hospital, also noted that the proposed changes to Poole Hospital were fully supported by the Hospital itself.  He noted that it had taken 5 years to reach this point and implementation of the changes would take another 4-5 years.  In addition to other views expressed, Poole Hospital also felt that the review could not afford a delay from a referral to the SoS for Health.  There was still lots of opportunity for further detailed discussion on changes, but the national funding was not available indefinitely and progress needed to be made to enable an exciting future for Poole Hospital.

Financial Plan

The Financial Plan was part of the wider Sustainability and Transformation Plan and Clinical Services Review decision making process. Assurance had been given by NHS England through the process for securing national funding of £147 for the transformation of services in Dorset.  The Plan would continue to be developed through investment into community, primary care and mental health whilst managing the reconfiguration of acute provision.

Reduction in Acute Beds

Bed movements were explained as part of the focus to increase care in people’s homes and in the community through integrated services, and avoid people entering the acute hospital setting.  Planned Hospitals would then work to reduce patient time spent in hospital, and result in less need for beds from 1810 to 1632.  The situation was more complex for Emergency Hospital settings, but was part of the whole picture of what bed shape would be needed for the future.

Equality Impact Assessment (EqIA)

The CCG had considered the variance of needs across all protected characteristics, and geography of Dorset, through clinical teams and through sense checking through a Patient, Carer and Public Group, which considered the clinical design and data.  Other wider groups were also involved in the process for sense checking.  Feedback was fed into the formal EqIA through an independent review and workshop with groups.  The EqIA would continue to develop and was treated as a live document at the heart of CSR.  Moving forward there would be a Patient Group with an independent Chairman to provide an assurance role in addition to the formal scrutiny process.

Concern about the ‘minimal impact’ conclusions of the EqIA not reflecting the issues within the document was raised, to which the CCG indicated that the document would be further developed to reflect issues about travel times; impact on rural and deprived areas; child poverty; disabled travel arrangements; teenagers access from Weymouth and Portland; and cuts to public transport.

It was explained by the CCG that existing services would have similar impacts to those detailed in the EqIA.  There were a difficult set of issues faced and the CSR would seek to improve outcomes through the proposals around acute and community provision, but would not be able to resolve every issue. 

Cllr Jon Orrell, County Councillor for Weymouth Town, addressed the Committee as a local councillor and as a GP to express his view that there needed to be sustainable change through Prevention at Scale to ensure community integration of health and social care.  He explained that the need for ongoing savings had previously resulted in community services being diminished after a reduction in hospital beds.  He also expressed the need for health organisations to recognise and have regard to the democratic process when reviewing services.  Dr Forbes Watson, as the Chairman of Dorset CCG, refuted the claims made by Cllr Orrell and attention was drawn to the plan explained in detail at the meeting, which was leading wider influence on NHS systems and would impact on provision beyond Dorset across the Country.  He also confirmed that the plan constantly responded to change and could be modified to meet demands and needs.

Recognition was given to the need to ensure the best use of assets through facilities and buildings to best serve Dorset.  The focus of the CSR was repeated by the CCG, that it would provide what was best for the general public and what was in the best interests of patients.  Original proposals looked at acute provision differently in relation to locations of emergency and planned hospitals, but through the extensive review process the proposals had been changed and refined, through testing and assessment of sites to provide a model which was the most sustainable for Dorset.  The £147m funding from the NHS would also allow reconfiguration to take place through the best utilisation of assets.

In relation to the impact across Dorset, and on DCH in particular, if Poole Hospital was to retain A&E and major trauma services, it was explained that although there would not be a downgrading of DCH there would need to be consideration given to the services that had been reserved for DCH as it was not possible to keep all services at all sites.

At the end of the debate the Chairman summarised the areas considered throughout the meeting including the contributions from professionals and health partners, and that a decision was needed based on service provision for the whole of Dorset, not just Bournemouth and Poole.  He explained that in his view the continuation of a referral to the SoS for Health did not meet the necessary criteria for referrals and proposed an additional recommendation, subject to the referral to the SoS for Health not being progressed, to support the JHSC’s resolution regarding the joint scrutiny of the capacity and performance of ambulance services.  A further request was made to include detailed scrutiny of transport arrangements related to the changes.

On being put to the vote, the Committee voted to not progress the referral to the SoS for Health, and agreed the additional recommendation above.

Resolved

1. That the presentation by NHS Dorset Clinical Commissioning Group be noted; 

2. That the outcome of the Joint Health Scrutiny Committee meeting held on 12 December 2017 be noted;

3. That, in light of the further information that has been provided and developments that have taken place, the Committee do not proceed with a formal referral to the Secretary of State for Health; and,

4. That the Joint Committee’s resolution that some detailed (joint) scrutiny work around the capacity and performance of the ambulance service be supported, and detailed scrutiny of transport arrangements related to the changes would also be undertaken.