Agenda item

The CCG and OUHFT to report to the Horton HOSC, in line with their timetable, on the recommendation to be made to the CCG Board (on the 26^th of September) on the future of obstetrics at the Horton General Hospital.

 

The paper accompanying this item will be published as an addenda to the papers on the 16^th of September

The Committee had before them the report to the OCCG Board on 26 September 2019 and supporting appendices.

 

The following attendees were at the table: Lou Patten, Chief Executive OCCG; Dr Bruno Holthof, Chief Executive OUH and Professor Meghana Pandit, Medical Director, OUH. In addition, Veronica Miller, OUH and Catherine Mountford, OCCG came to the table to respond to specific points made.

 

The following statements were made and are set out in full:

 

Lou Patten

 

‘At the start of this programme the IRP asked OCCG to do three things:

 

1.    To fully understand current and future demand for maternity services, taking into account housing/population growth across the wider area of north Oxfordshire, south Northamptonshire and south Warwickshire.

2.    To take a fresh look at the options, to thoroughly review the options previously included and to include any additional options identified.

3.    To clarify any potential co-dependencies of services linked to obstetrics at the Horton.

 

In delivering this programme we have worked with stakeholders including those from north Oxfordshire, south Warwickshire and south Northamptonshire. We have been open and shared information publically at every stage. We set out our plan at the outset, agreed by the Joint HOSC, and have reported progress at every one of your seven previous meetings.

 

The process has been thorough and complicated at times as we have got into the complex detail of staffing models, recruitment, patient experience, clinical safety and national guidance.

 

OCCG have received written confirmation from NHSEI that they are assured that the process we have followed has delivered what was asked of us and this letter is published on OCCG website.

 

We have seen the JHOSC Chair’s addendum in response to our published Board paper and note several areas that require clarification or correction; whilst we may have the opportunity to go through this today, we have prepared a written response that will be passed to the Chair today and made available on our public website on Friday morning.

 

Most importantly, I need to ask that one particular point is retracted immediately about smaller hospitals that suggested other hospitals might lie or stretch the truth. I don’t believe this was accurately reported.

 

Oxfordshire Clinical Commissioning Group understands the recommendation set out in our Board paper will be hugely disappointing for all those who want to see obstetrics return to the Horton. However, although a recommendation has been made, a final decision is still to be discussed and made by the OCCG Board on 26 September.

 

It is really important for the JHOSC to note that the recommended option if agreed will be a very different decision to that taken by the CCG Board in 2016. There are a number of differences that I wish to point out.

 

·         In March 2018 the CCG Board overturned the decision to consult on the removal of A&E and Paediatrics; these services will stay at the Horton. System Leaders agreed that the Horton provides a significant suite of services to the people of Banbury & surrounding areas and that this was to be built on rather than taken away. We continue our commitment to building a strong future for the Horton General Hospital.

·         Another key difference is that this recommendation to the OCCG Board is not for a permanent closure of obstetrics. The recommendation is that at this point in time, because of the balance of the sustainability and therefore clinical safety, the recommendation has to be to maintain closure at present.

·         I wish to remind JHOSC members that we have set in stone with the HWB, supported by the Oxfordshire HOSC, a process for reviewing our population health and care needs at regular intervals, so that this decision can be reviewed if critical factors change.

·         How can such critical factors change?

o  Well, in terms of the current birth rate, whilst it is dropping at present, it may well increase with the proposed housing developments. We need to watch this carefully, together.

o  In terms of changes to recruitment and retention, our learning from this process is that the current state of the Horton estate does not lend itself to encouraging clinicians to work there.  Having a hospital that is fit for purpose would significantly enhance our opportunities to encourage staff to come and work here, and – regardless of the Board decision, we must unite our voices in asking for significant capital investment to ensure we have flexible clinical space that is fit for the 21^st century.

o  National changes to training could result in an increase in in the number of qualified obstetricians in the country.

o  In the event of any of these factors changing, then together, as part of an integrated health and care partnership (for which we have been officially recognised) we can review this decision as that may be enough to tip the balance in favour of a more sustainable service being delivered.

 

We understand the frustrations but I want to finish by stating that we have learnt much from this engagement experience. We believe it has been a robust, open and transparent process which has gathered a wide range of information, views and feedback from the people who matter most. We are keen to ensure we continue an open and ongoing dialogue with local stakeholders about health needs and local services in the future.’

 

Professor Meghana Pandit

‘I have been asked to share my clinical perspective and be available to answer questions particularly on  clinical outcomes, safety and medical staffing 

 

·         I want to start by reassuring everyone that providing a clinically safe service for patients is the Trust’s number 1 priority. Our experience of running the single obstetric model over the past two years, demonstrates that this service can be run safely and sustainably.  The CQC rated our service good in their report early this year.

 

·         Clinical outcomes are improving: The number of still births has fallen every year since 2016 as a percentage of births. The number of babies with poor outcomes (moderate to severe brain damage) has also steadily fallen.

 

·         Whilst the patient feedback during this process has given us very valuable input on where our service needs to improve, it is also positive overall about the care our patients receive – including women from this area.

 

·         Cherwell residents were particularly positive about ante-natal care, a good proportion of which is delivered from the Horton. For example, over half of women have had scans and bloods at the Horton and we operate a range of antenatal and postnatal clinics here such as perinatal mental health and breast feeding support.

 

On the two obstetric unit model:

 

·         As you have heard before and can see from the paper, the NHS faces ongoing and severe workforce challenges, nationally and locally, in obstetrics, anaesthetics and neo-natal nursing.

·         Staffing clinical rotas in line with rules – rightly in place to ensure patient and staff safety – is complex and challenging.

·         I hope Members will see from the papers we have looked hard at options to address these challenges. But we cannot be certain of success and we would need support from other organisations to deliver, which may not be forthcoming.

·         Therefore, even with these mitigations, we remain highly concerned that we could not sustainably staff the required rotas for a Horton obstetrics unit and therefore could not guarantee to run a safe service for patients.

 

On a single obstetric model

 

·         As I said at the start, we feel confident that the single obstetric model can provide a safe, sustainable service, given present challenges. However, we recognise the negative impact on patient choice and experience for women in this area that have been raised through this process.

·         Patient stories that were heard as part of this process were difficult to hear, as some of them were so far from the experience we would all want to have. We are grateful to the women and their families who have shared their stories and we found the patient survey to be immensely valuable. We are very committed to acting on feedback to improve services.

·         Our suggested actions on the single obstetric unit model around increasing the amount of ante-natal and post-natal care at the Horton; improving patient information; and doing what we can to improve access to the John Radcliffe site are based on this feedback. 

·         But, if the CCG’s recommendation is accepted, we would do everything we can to work with local partners such as Maternity Voices, women and their partners to minimise any negative impacts from the longer distance to travel.

 

I want to reassure people that the Trust’s absolute top priority is to ensure a safe service for all our patients.

 

Dr Bruno Holthof

 

‘Thank members of the committee and the people in the trust and CCG who have worked hard behind the scenes. I want to thank particularly the clinicians who have worked on this project.

·         I know people locally will be disappointed by the CCG’s recommendation.  I am also disappointed. We don’t have enough anaesthetists, band 5 nurses and workforce is, after clinical safety, our number one priority.

·         We have a new Prime Minister and new Secretary of State who have committed funding for hospitals. We as a trust are committed to rebuilding the Horton. It is important that we work with the local community to agree what services and buildings we want at the Horton. We have committed to expanding the emergency department, increasing the scanning, more day cases and other services.

·         While legal proceedings were on-going we were advised not to apply for funding but since those were concluded we have applied for funding. We will shortly appoint advisors to work with us on this.

·         I confirm that as I have said to this Committee before and as our Medical Director has just said, providing a clinically safe service is my number one priority.

·         I note the CCG’s recommendation that this decision would be for the foreseeable future and should be reviewed if circumstances (birth rate, workforce availability, capital availability) change.

·         I hope people will acknowledge that the Trust with the CCG has put in a lot of time and effort to this process, exploring all the options.  We are grateful for all the ideas and challenge from the HOSC and local community and campaign groups, which have encouraged us to look at different models.

·         Whatever decision the CCG Board makes, the Trust is committed to working with local partners and the community to make our maternity services as good as possible for our patients. 

·         I want to talk more broadly about the Horton General Hospital. It is a hugely important part of Oxford University Hospitals and we want to invest in its future – working with the community. We really value the way that the Horton is treasured by the local residents of what is sometimes known as ‘Banburyshire’.

·         We share your desire to see expansion of the services that we provide here and to improve or rebuild buildings. New facilities will help give certainty to staff and the community on our commitment to the Horton – and should help improve recruitment and retention.

·         The Trust is keen to press ahead with developing a masterplan for the Horton site and to make a compelling business case to government for significant capital investment in the Horton.  We hope we will have the community’s support and engagement in doing that. 

·         Our local MP and local Cherwell councillors – Councillor Wood and Councillor McHugh - have made it clear to us they wish to see tangible actions to demonstrate our commitment. The Trust will therefore immediately proceed with initial phases of master planning the Horton site at our own cost. Expert external advisors will be appointed to support us on this by the end of September.

·         We will be keen to arrange an early meeting between the Trust, local system leaders and our advisors to ensure we are capturing local aspirations for the site from the start of the process.

·         And, if the CCG Board accepts the recommendation, we will build in flexibility so that an obstetric unit can be opened at the Horton in the future if circumstances demand.’

Dr Holthof, responding to a point made by the speakers about lack of application for funding confirmed that they had been advised that they would be unsuccessful whilst there were on-going legal proceedings. Once ended they had applied.

 

Councillor Arash Fatemian thanked Lou Patten, Professor Pandit and Dr Holthof for their opening statements. Responding to the request made by Lou Patten to retract the statement in his addenda as referred to in her statement above the Chairman stated that that was his current understanding, but he was happy to discuss outside the meeting and to retract the comment if proved in error.

 

The Chairman in his opening remarks referred to the possible position in 2 years’ time where needs have changed, and a growing demand meant that there was a wish to reinstate maternity services. The process to scope and apply for funding would be lengthy. He feared that it would be similar to the position with Wantage Community Hospital and that the concept of only closing for the foreseeable future not being permanent did not stack up. Responding Lou Patten stressed that the current proposals were very different to permanent closure. The position would be modelled on a regular basis. They would work proactively to redevelop the Horton and it was still a working hospital. It would continue to have its services reviewed for the needs of the population.

 

 

Councillor Fatemian referred to the meeting of Oxfordshire Joint Health Overview & Scrutiny Committee and comments made there by Dr Holthof in relation to the PET CT scanner item. The Chairman stated that Dr Holthof had commented that the Trust did not see accessibility as an issue of quality and that access was not an important factor. Dr Holthof responded that the Trust strategy was about endorsing the place-based model and they would endorse any initiative that ensured people were diagnosed and treated locally. They were committed to keeping patients as local as possible and were developing new strategies including using new technologies to achieve this.

 

Representatives responded to questions from Members:

 

·         Asked what population growth in numbers or percentage would trigger the reinstatement of services Lou Patten advised that it was not a simple question of numbers but a complex issue. Growth would be cross referenced with local complexity with factors such as maternity flows, local demographics and workforce issues. On demographic issues they were able to track patients using registered patient lists in order to map demographic trends. She referred to the suggestion that the position would be looked at on a regular basis. The Chairman commented that if there was not clarity on the criteria it would not rebuild trust.

·         Responding to the point that by encouraging mothers to go to Warwick or Gloucester it was perpetuating the reason (of low birth numbers) for closure Lou Patten explained that this was something that could be tracked.

·         It was confirmed that the current ambulance at the Horton in case of emergency would be retained if the proposals were accepted.

 

During discussion Members made the following points:

 

·         A member commented that it was a good piece of work by the Trust looking at the population projections. However even with higher numbers it seemed to him that the trigger point had to be the ability to have a sustainable workforce.

·         A member highlighted that the piece of work undertaken by Pragma had been impressive. It was a substantial piece of work that was not mentioned in the main paper to the OCCG Board.

·         A co-opted member (who had no vote on this Committee) who had been part of the Stakeholder Group looking at options scoring commented that it was regrettable that he had not seen the weighting nor how they were applied. The criteria had been presented to them by OCC. He expressed some concern that it was possible depending on the criteria and weighting to build in bias. It was an important issue when relying on the type of scoring used with an option coming out on top but not doing it based on deliverability and workforce issues. Lou Patten replied that they had used best practice and had been supported by the Consultation Institute. The weighting had been sent to Councillor Fatemian, to Nick Graham, Monitoring officer and published on the web site. The intention was to reduce the options to take forward. There had been two options everyone had agreed were worth taking forward and then the next stage was safety and sustainability. The Chairman stated that in his view information had not been shared as agreed. Lou Patten disagreed.

·         A member highlighted the prominence of cost and deliverability in the report. He had been on the Committee since it had begun and costs had not featured since the initial discussion due to the difficulty in getting answers to financial questions. It was troubling to find out the cost implications at this late stage and it was suggested that this revealed the agenda that lay behind the proposals. In response Dr Holthof stressed that safety was the key driver over finance. Cost was one of the criteria and they had looked at cost rather than revenue. Lou Patten added that OCCG had a responsibility to consider financial implications as holders of the public purse.

·         Responding to a member who raised discrepancies in the cost of Option 9 in the report (which had come top of the scoring) compared to figures in a conditions survey Dr Holthof undertook to look at the document. It was noted that refurbishment costs would be markedly different to rebuilding costs.

·         A member referred to the second paragraph of page 29 and sought clarification whether it meant that that costs were an issue, that should a second maternity unit be funded it would have an impact on other maternity and wider provision and that it would not be a priority for funding. Lou Patten explained that they were constantly trying to balance a finite budget and it would be for discussion.

·         A member noted that he had raised the issue of recruitment at previous meetings. The report gave him no confidence that there had been a robust recruitment campaign as there was a lack of evidence. He could suggest that it was convenient for there to be the current shortages. The Committee was advised that the Board paper was an overview and the Board had already considered detailed work on this matter. Professor Pandit detailed the efforts made to recruit staff, including the steps taken and the use of specialist HR staff. Dr Holthof added that they had absolutely carried out international recruitment. The fact was that there were not enough doctors and nurses.

·         A member questioned the practicality of steps set out in 4(a) and (b) to improve the experience for mothers and birth partners to the JR. He sought assurance that the provision for birth partners to stay overnight would not be removed when the space came under pressure. Lou Patten replied that that was about oversight to ensure that provision was effective. The emergency parking was already successfully in place at the JR.

·          Concern was expressed that with regard to recommendation (c)  that this still entailed a long journey of 20-25 miles. It was queried whether there were journey times from Banbury to Warwick. It was also queried whether it was known if there were any capacity issues. It was suggested that the Warwick hospital could face similar problems to the Horton as services were likely to be focussed on the Coventry and Warwick Hospital site. It was queried what work had been done on this to ensure future proofing of the preferred option. 

·         It was suggested that retaining mothers in the County who were being encouraged to look elsewhere would increase income. The Trust already had an attractive option and that was the Horton General Hospital if that would only be realised and services funded. Lou Patten commented that it was best practice to ensure mums had all the information to make an informed choice. Option 4 (c) was about strengthening links to other hospitals in the area. The work they had done had helped them to understand that the Trust’s borders were not borders for mums.

·         A member queried the information contained in Tables 7 and 8 of the report. He queried whether a second maternity unit would not attract more mothers making the per baby cost of the two-unit model less. Catherine Mountford commented that the modelling took into account the catchment of the Horton at the time but that it would be monitored. It was noted that if a second unit was not opened it would be difficult to assess how many additional births it would attract. Catherine Mountford indicated they would look at the number of births in Banbury and the surrounding area. Currently the birth rate was going down.

 

There was a brief adjournment at 8.19 pm with the Committee reconvening at 8.25 pm.

 

Discussion continued:

 

·         Anaesthetists and gynaecologists had been successfully rotated and it was queried why this was not possible in obstetrics. Professor Pandit explained that 8 of the current 16 doctors worked on very complex cases. If they were to rotate it would reduce the specialist capacity. Others could be rotated but there would be a need for additional doctors to create the model which went back to the staffing issue.

·         There was some discussion over the impact of mother’s anxiety on the unborn baby and the continuing impact this could have on the child with issues such as social, emotional or behavioural difficulties, ADHD and complications at birth. This would have an implication  in terms of  continuing NHS care. It was queried how this cost had been factored in to the model. Professor Pandit recognised that women could be worried from the beginning of pregnancy, to the birth and beyond. She accepted the anxiety over maternity services and about labour. This general anxiety and stress were not the same as a clinical diagnosis. The Trust did provide support. The mental health of women was a national issue and the Trust was expanding its services to support women.

·         A member referred to the suggestions from Councillor Herring and noted that the Oxford to Cambridge arc was not referenced in the report. For mother in South Northants a lot of the anxiety was simply travelling down the A43/M40. There was an issue for mothers who having made that journey were turned away because they were too early in their labour. It was queried whether there was scope to improve the implementation plan. Dr Pandit undertook to look at what was possible.

 

Following the discussion, the Chairman highlighted the addenda setting out his response to the proposals presented. He stated that in his opinion the unsustainability of the Horton was of the Trust’s own making. Doctors resigned when news got out that the Horton was to be permanently downgraded. This led to its temporary closure. Members supported this view of the current position.

 

The Chairman commented that the starting point was the geography of the Horton General Hospital catchment. Lou Patten declined to respond to a question as to whether the residents of the area would be better served if the Horton became another Trust.

 

The Chairman thanked the OCCG and OUH for their attendance. He drew attention to the comments and recommendations set out in the Chairman’s report addenda and highlighted that the question for the Committee was whether it was satisfied with the adequacy of the consultation. Whether the scrutiny had been artificial given the reliance in the OCCG paper on finance and cost. For adequate consultation to take place it must take genuine account of mother’s views and experience. If the response is always to be ‘that we can’t do that’ then the Chairman questioned  the point of the exercise.

 

The Chairman stated that he did not believe that the proposals in the OCCG paper would be in the best interests of local people in the Horton catchment area. The proposals did not improve services and there were issues of accessibility and choice. The Committee had not been convinced by the workforce issues feeling that where there was a will then a way would be found. It had been possible to recruit 4 doctors despite the difficulties. The Chairman suggested that if the Trust was able to deal with an expected 60,000 to 90,000 emergencies then it should be possible to plan for 1500 births. The workforce issues were surely similar across all services.

 

Referring to the proposals to enhance the user experience at the JR the Chairman suggested that rather than a response to concerns raised by the IRP these were improvements that should already be in place. Provisions such as emergency parking were not just applicable to maternity services,

 

The Chairman proposed the recommendations contained in the addenda but proposed an additional recommendation. He referred to points 6 and 7 in the OCCG paper that suggested that partners work together to develop a masterplan for the Horton General Hospital and to pursue capital investment. In light of this the Chairman proposed that the Horton Joint Health Overview & Scrutiny Committee continued to meet and accepts in good faith that partners are genuine in working to improve Horton General Hospital and that we will continue to meet to hold OUH and OCCG and others to account in the development and implementation of the positive vision for the future of the Horton General Hospital.

 

It was:

 

AGREED:     (nem con)

 

 

(a)        That if decisions are taken at the meeting of the OCCG Board, as per the board paper, to refer the decision to the secretary of state on the following grounds:

 

I. The Horton HOSC is not satisfied with the adequacy of the content of the consultation (Regulation 29(9)(a)).

 

II. The Horton HOSC believes the proposal would not be in the interests of the health service in this area (the latter being the cross-boundary area represented by the Horton HOSC) (Regulation 23(9)(c).

 

The detail of this referral to be based on the comments in the above minutes and the additional information as set out in the Chairman’s addenda.

 

(b)         that the Horton Joint Health Overview & Scrutiny Committee continueto meet and accepts in good faith that partners are genuine in working to improve Horton General Hospital and that the Committee will continue meet to hold OUH and OCCG and others to account in the development and implementation of the positive vision for the future of the Horton General Hospital.