Agenda item

MORNING SESSION

 

David Smith, Chief Executive, and Catherine Mountford, Director of Governance, Oxfordshire Clinical Commissioning Group (OCCG) will present final proposals for Phase 1 of the Oxfordshire Big Health & Care Transformation Programme that will go forward for discussion and decision at an extraordinary meeting of the OCCG Board on 10 August 2017.

 

The final proposals will make recommendations in relation to:

 

·         The use of acute hospital beds across Oxfordshire;

·         Planned care services at the Horton General Hospital, Banbury;

·         Stroke services across Oxfordshire

·         Critical (intensive) care services at the Horton General Hospital, Banbury; and

·         Maternity services, including obstetrics, the special care baby unit and emergency gynaecology services at the Horton General Hospital, Banbury.

 

On 22 June the OCCG presented feedback from the public consultation (held between January and April) to the Committee and outlined further work being undertaken to inform their final decisions. The Committee requested to meet again with the OCCG to scrutinise and comment on the final proposals before they are discussed by the OCCG Board in August.

 

The OCCG’s Board papers for the 10 August meeting will be available from 3 August 2017 and the following OCCG papers will be published as part of an Addenda going to this Committee as soon as it is possible to do so:

 

·         The decision-making business case outlining the final proposals for Phase 1 of the Big Health and Care Transformation Programme;

·         The draft Minutes of the OCCG Board meeting held on 20 June 2017 at which the Phase 1 consultation outcomes were examined;

·         The results of the OCCG commissioned Integrated Impact Assessment for Phase 1, including a travel and access analysis;

·         The results of an OCCG commissioned parking survey at the John Radcliffe and Horton General Hospital sites undertaken by Mott McDonald; and

·         The results of an OCCG commissioned qualitative survey undertaken by Healthwatch Oxfordshire capturing patient experiences of travelling and parking at Oxford University Hospitals NHS Trust sites hospital sites.

 

For ease of reference, the following background papers are attached for information:

 

·         Minutes of the 7 March 2017 HOSC meeting to scrutinise the Oxfordshire Big Health and Care Consultation – Phase 1;

·         HOSC’s formal response and recommendations in relation to the Oxfordshire Big Health and Care Consultation  - Phase 1; and

·         Oxfordshire Clinical Commissioning Group’s reply to HOSC’s response and recommendations

·         Draft unconfirmed  Minute of the 22 June 2017 HOSC meeting – Item 9 ’Oxfordshire Transformation Plan – Phase 1 consultation outcomes’

 

OCCG representatives will attend to explain the reasons behind the commissioning of additional work in a number of areas following the consultation; and also how this information will be used to inform the Board’s final decisions on 10 August.

 

Committee members are requested to ask questions for clarification only at this point.

 

 

Speakers or petitioners to the Committee

 

 

LUNCH

 

 

AFTERNOON SESSION

 

Questions from the Committee

 

OCCG representatives will be invited to respond to the comments and concerns about the impact of the final proposals on patients, the public and the local health service raised by the speakers during the morning; and from  members of the Committee.

 

 

BREAK

 

 

Committee comments and recommendations

 

The Committee will then consider whether the final proposals are in the best interests of the health service in Oxfordshire and to make comments on the recommendations to inform the OCCG Board’s discussion on 10 August 2017.

 

David Smith, Chief Executive, Oxfordshire Clinical Commissioning Group (OCCG), Catherine Mountford, Director of Governance, OCCG, Dr Tony Berendt, Medical Director, Oxford University Hospitals Trust, Sarah Adair, Head of Communications and Engagement, OCCG, Simon Angelides, OTP Programme Manager, OCCG and Stuart Bell, Chief Executive, Oxford Health NHS Foundation Trust were in attendance.

 

David Smith, Chief Executive, Oxfordshire Clinical Commissioning Group (OCCG), Catherine Mountford, Director of Governance, OCCG, Dr Tony Berendt, Medical Director, Oxford University Hospitals Trust, presented final proposals for Phase 1 of the Oxfordshire Big Health & Care Transformation Programme that would go forward for discussion and decision at an extraordinary meeting of the OCCG Board on 10 August 2017. They explained the reasons behind the commissioning of additional work in a number of areas following the consultation; and also how this information would be used to inform the Board’s final decisions on 10 August.

 

The Committee had before them the following OCCG’s Board papers:

 

·         The decision-making business case outlining the final proposals for Phase 1 of the Big Health and Care Transformation Programme;

·         The draft Minutes of the OCCG Board meeting held on 20 June 2017 at which the Phase 1 consultation outcomes were examined;

·         The results of the OCCG commissioned Integrated Impact Assessment for Phase 1, including a travel and access analysis;

·         The results of an OCCG commissioned parking survey at the John Radcliffe and Horton General Hospital sites undertaken by Mott McDonald; and

·         The results of an OCCG commissioned qualitative survey undertaken by Healthwatch Oxfordshire capturing patient experiences of travelling and parking at Oxford University Hospitals NHS Trust sites hospital sites.

 

The Committee also had before them for reference the following:

 

• Minutes of the 7 March 2017 HOSC meeting to scrutinise the Oxfordshire Big Health and Care Consultation – Phase 1;
• HOSC’s formal response and recommendations in relation to the Oxfordshire Big Health and Care Consultation  - Phase 1; and
• Oxfordshire Clinical Commissioning Group’s reply to HOSC’s response and recommendations
• Draft unconfirmed  Minute of the 22 June 2017 HOSC meeting – Item 9 ’Oxfordshire Transformation Plan – Phase 1 consultation outcomes’

 

In response to questions from members of the Committee on points of clarification health representatives made the following points:

 

1. Asked about the reduction in income from district general services they stressed that these services were important and that they had a vision for modern hospital service for Banbury which they could not realise whilst the consultation process carried on.
2. They were unable to confirm if they had been able to make use of traffic data from the County Council.
3. They expressed confidence that patient outcomes would be better under the proposals.
4. Asked to explain the validity of the rebalancing the system pilot as a driver for bed closures given lack of evidence that it was effective they refuted that this was the case. The resources released by the pilot had already been redeployed in the system. The accepted that any further bed closures should await the reduction in figures on the delayed transfer of care.

 

The following speakers addressed the Committee:

 

Victoria Prentis MP, highlighted the housing growth figures in Oxfordshire which were 5 times the national rate. She stressed that residents were anxious about the future of the Horton General Hospital (HGH) which had been under threat for many years. She highlighted the domino effect of losing services and with one anaesthetic rota already gone there was fear for the future of A&E. Residents were also frightened about the safety of mothers and babies particularly those requiring transfer to the John Radcliffe (JR) either during labour or immediately after. There were concerns about travel times and she expressed the view that there was a lack of real evaluation of travel times. Victoria Prentis,MP referred to her travel survey which she felt had been ignored. Residents were angry about the process. Holding a split consultation was wrong; information was inadequate and timelines confusing.

 

Robert Courts MP, urged the Committee to seek an independent review speaking against the proposals due to the impact on West Oxfordshire. He expressed concerns about process, safety and the future of Chipping Norton Community Hospital. He commented that split consultation had failed to take into account the future of health care as a whole and the consultation ignored the impacts of population growth. On safety he questioned the ambulance journey times to JR which he felt were unrealistic. He highlighted the expected reduction in births at Chipping Norton Midwife Led Unit (MLU) and was concerned for the future of this and other MLUs.

 

The Rt Hon. Tony Baldry urged referral to the Secretary of State. He stressed that the impact of the proposals would be County wide. They would increase the pressure on the JR and he highlighted a capacity issue. He referred to the IRP judgement in 2008 and suggested that the Committee should have it before them to consider. He commented that nothing had changed since those very clear recommendations against removing maternity services from HGH except that the population had grown.

 

Councillor Kieron Mallon spoke against the proposals and highlighted the 2008 IRP judgement. He referred to: the lack of choice for pregnant women in Banbury and surrounding areas; the uncertainty over the future of the static ambulance currently provided, the lack of an impact assessment on social care beds as a result of the split consultation which meant meaningful representations were not possible. Councillor Mallon asserted that witness statements had been ignored and that there was a lack of trust by local people caused by poor engagement, lack of forethought and preconceived opinions on behalf of the OCCG.

 

Councillor Tony Ilott highlighted journey times to JR from his Division in the event of problems. He referred to expected housing growth that would exacerbate travel and access issues to the JR.

 

Councillor Lynn Pratt, as a Town and District Councillor for Bicester, spoke in support of a fully functioning district wide hospital at HGH. She highlighted ramifications for Bicester and surrounding villages of the loss of maternity services. Referring to the figures she believed that the number of births had been underestimated referring to future population growth with Bicester expected to double in size by 2030.

 

Councillor Eddie Reeves spoke against the proposals in terms of the current downgrade already having a detrimental impact on the ability of residents of Banbury to access high quality health care. He highlighted the dangers of an over reliance on a stretched JR with poor access. Further centralisation was not in patients’ best interests. He referred to an historic lack of investment at HGH. He gave some welcome to the investment in a diagnostic centre but not at the expense of a further loss of acute services. He noted the lack of detailed plans or funding to ensure plans came to fruition.

 

Rosalind Pearce, Healthwatch Oxfordshire stated that they were unable to support the OTP on the following grounds:

-       Capacity issues – population growth meant any proposal to close another 36 beds was unsustainable

-       Economic growth will bring highly skilled young people in to the Country and will lead to an increase in the birth rate

-       In relation to stroke services there was concern that the national agreement to downgrade response times was at odds with the need for a quick response and further review was required.

-       Travel and parking would be made worse by more activity on fewer sites.

-       The concentration of services was a threat to the resilience of services.

-       The split consultation was flawed.

 

In conclusion she stated that concerns were so great and so deep that the proposals should not go ahead until there was greater understanding and better consultation.

 

Bishop Colin Fletcher urged the Committee to refer the proposals for further work. He highlighted that in North Oxfordshire and over the County boundaries in that area people looked to HGH. The journey to JR was very difficult and parking was a problem. He expressed concern over the two stage process and the uncertainty for residents and staff at the HGH and the local distrust this had caused.

 

Dr Peter Fisher, a member of the public and retired consultant at the HGH rejected the idea of a 2 phase consultation stressing that services at the HGH were interdependent and must be considered as a whole. He argued that the basis of clinical urgency for Phase 1 was not valid and urged that it be considered alongside Phase 2. In particular it was perverse to make permanent decisions on maternity services when still trying to recruit and it was unwise to make decisions on bed closures before the community services were in place and before seeing the impact of winter bed needs.  He considered the stroke proposals not to be controversial and to make common sense. 

 

Ian Davies, Director of Operational Delivery, Cherwell District Council and South Northants Council expressed concerns about the consultation process. He referred to the ‘Better Births’ recommendations and to a practicable alternative model proposed by Cherwell DC which they felt had not been given serious consideration. He stated that selective use of the Better Birth recommendations had led to an urban model in a rural area. The loss of obstetric services removed choice with over 50% of women using HGH being transferred. There was a lack of support for a free standing MLU as opposed to an alongside MLU.

 

Roseanne Edwards, Newspaper Health journalist, Banbury Guardian highlighted population growth and that Census data used in the OTP was out of date. She noted that in the past HGH had been a safety valve for pressures on the JR and queried the impact of this in the future. She stated that information had been kept secret and alleged that at a consultation meeting Tony Berendt had accepted there would be a 5% mortality rate as a result of the OTP. She questioned the process by which training accreditation had been removed from HGH and the commitment to resolve the problem of recruiting mid-range doctors. Tony Berendt put on record that he did not recognise the comment attributed to him.

 

Valerie Ingram, administrator of ‘Save our Horton’ facebook page urged referral and spoke in particular against the proposals for maternity services by reference to the individual experience and the death of a baby suffered by a pregnant woman and her family.

 

Joan Stewart, ‘Keep our NHS Public’, submitted a petition in the following terms:

 

‘We entreat you to reject Phase 1 of the Oxfordshire Transformation Programme because:

·         It entails closing hospitals and health facilities that belong to us

·         It will give the people of Oxfordshire a poorer, cheaper service than they had before

·         It will lead to overcrowding and longer waits at the JR and Churchill

·         It will make things even more difficult for those without transport, and those living alone

·         It is based on the false idea that the government must cut funding to the NHS (funding can be found and taxes for the rich raised).

Please demand that Phases 1 and 2 be consulted together and agreed with West Berkshire and Buckinghamshire across the whole STP population’

 

Speaking in support of the petition Joan Stewart expressed concern at the inadequate time given to digest the Board papers and prepare questions and at the lack of genuine consultation. The Group found the business case flawed and unconvincing with flimsy mitigation. She raised a number of issues:

-       Workforce pressures

-       Travel & journey times

-       The need for a safe, reliable, sustainable and affordable ambulance service

She stated that there was nothing in the financial plan to assure the Group that issues would be addressed. Millions of pounds of funding would be required to bring about enhanced services.

 

She commented that improvements to the Delayed Transfer of Care (DToC) figures had failed to materialise and she expressed doubt about other alternative services which had increased costs and whose future were in doubt.

 

Charlotte Bird, Press & PR for ‘Keep the Horton General’ campaign expressed her concern at the lack of notice given to views expressed during the consultation. She also queried the information and conclusions of a number of the consultants used for specific pieces of work including the parking survey.

 

Keith Strangwood, Chair of the ‘Keep the Horton General’ campaign in supporting referral of the proposals urged local MPs and Rt Hon Tony Baldry to come together in parliament with others to fight for funding for the NHS.

 

Sophie Hammond, ‘Keep the Horton General’ campaign queried why if there was a genuine commitment to retaining the training accreditation, which was subsequently lost, consultants had been allowed to neglect their training duties. She spoke against the proposals on maternity services by reference to her own experience when at the HGH where following a routine birth emergency surgery had been required and which  would now require a transfer to the JR. She also referred to other anecdotal evidence of pressures on the JR with mothers being in labour in the waiting room and one mother being sent to Wallingford.

 

Chrissie Ansel, speaking on behalf of Kelly Cowley, a member of the public informed the Committee that local people did not feel adequately informed or consulted. Consultation meetings had been held at inconvenient times and there had been a lack of information. The literature provided did not explain how the changes would be made nor the impact. Population growth figures were out of date and papers had been designed to produce the required outcome. Local people would suffer financially through the changes due to increased travel costs. She was concerned at the future of the static ambulance. She noted that having friends and relatives able to visit is a part of recovery. The most vulnerable members of society would be affected by the proposals.

 

Jenny Jones, member of the public expressed disappointment that other options (page 80) had been too readily rejected. She supported an independent review to increase confidence in the solutions. Details of a recruitment agency had been passed to OUHT but she was disappointed at the lack of flexibility shown by OUHT in their processes to allow candidates to work towards registration. She queried the commitment to finding recruits when this would undermine their argument to downgrade the HGH.

 

Councillor Barry Wood, Chairman of Cherwell District Council requested the Committee to stand up for local people and to refer the proposals to the Secretary of State. He explained why Cherwell DC was continuing with Judicial Review:

-       In order to stand up for local people

-       To ensure things were done lawfully but to highlight failures:

o   Split consultation

o   Failure to provide information including annexes

o   Failure to comply with NHS Act 2006

He commented that no consideration had been given to their imaginative and innovative plan. He urged the OCCG to contact Cherwell DC with regard to the Capital Programme.

 

During questions to OCCG from members of the Committee the following points were made

 

·         With regard to free standing MLUs Tony Berendt clarified that the provision of free standing MLUs was evidence based and endorsed by NICE. Free standing MLU’s were an option for low risk births.

·         Asked about funding David Smith was clear that the reason for the consultation was patient care quality and safety. Funding would be revisited in phase 2 but it was a fact that OCCG was the lowest funded CCG per capita and funding was not keeping pace with demand. He was happy to come back to the Committee with more information with regard to funding.

·         Tony Berendt considering the domino effect agreed that it was necessary to look at interdependencies and linkages. It was correct to say that changes in anaesthetics have to be thought through to ensure it does not impact on other services. They did not see acute medical or A&E services being affected.

·         With regard to parking at the JR site Phase 1 would see a net increase in people visiting Banbury which should help parking at the JR. With regard to improvements there would be a focus on flow, access and signage even if as suggested by a questioner it was with the same number of spaces. They would continue to work with partners with regard to public transport

·         Asked about the problems to the plan posed by workforce issues it was explained that if anything those pressures were greater under the status quo and would be a threat to health care in the County.

·         Asked whether the personal cases referred to today by speakers had been investigated the Committee was assured that all incidents were investigated. Tony Berendt undertook to take back a request that the Committee in future receive anonymised information on such incidents. He would consider what could be provided whilst complying with the duty of confidentiality.

·         OCCG would be happy to discuss with them what financial support Cherwell Dc could provide.

·         Asked about plans for Witney Community Hospital it was confirmed that there were no plans to close either wards but that they were looking at the best location of beds. In response to further questions about uncertainty over the future of beds at Witney CH Stuart Bell advised that they were not moving stroke beds to the JR. They were looking at how best to organise beds. Community Hospitals often had patients with complex care needs over a longer period. They made use of hub bed arrangements.

·         In response to concerns that bus travel times were based on buses that were either not in existence or which ran a very limited service Simon Angelides advised the  Committee that travel times had been built on information from the national database and that he was happy to go through the specific concerns raised with him.

·         Asked whether the changes to bed numbers would put lives at risk this was refuted. A large amount of work had been put into the ambulatory services with the aim that where people did not need to remain in hospital they did not have to do so. 

·         An assurance was given that Phase 2 would take place with decision making expected in autumn next year.

·         Asked to define ‘significant progress’ in terms of reducing DToC figures David Smith referred to the 5^th test that had been brought in and that they were suggesting a figure of 120 beds (there were currently 170 beds in use). Success would result in further requests to close beds.

·         Asked what had changed since 2008 Tony Berendt highlighted:

o   Loss of training recognition

o   Public expectations

o   Changing legislation

o   Changed levels of safety assurance

o   A different financial environment

o   Hugh changes in workforce demographics

o                    An expectation of consultant delivered services and greater difficulty with middle grade doctors.

Pressed further on what had fundamentally changed that no longer required the provision of maternity services in North Oxfordshire Tony Berendt explained that it was not safe to have an obstetrics service that was not properly staffed and that it is safe to have a MLU endorsed by NICE.

• Asked if the lack of staffing was the only obstacle preventing a standalone obstetrics unit at HGH Tony Berendt stated that their continuing experience was that that middle grade tier had been difficult to recruit and retain.

• Responding to concerns about the length of papers David Smith advised that they had responded to the request for this meeting and following the Board meeting they would expect there to be follow through on the toolkit.
• It was confirmed that the independent body referred to in the papers would not be chosen by the OCCG.

 

During questioning Committee:

 

• Discussed concerns that the proposals would lead to the eventual removal or significant downgrade of HGH.
• Considered that underfunding of the NHS was a significant factor in the need for OTP.
• Expressed fears that the OTP was undeliverable due to workforce and funding issues.
• Commented that proper scrutiny of phase 1 was difficult without knowing the full picture to be provided by Phase 2 and STP.
• Were concerned at the domino effect on anaesthetics at the HGH, on other MLUs and on other services such as A&E and paediatrics.
• Raised travel and  access issues
• Considered whether there had been any material change since the IRP judgement that there was an absolute requirement to have a maternity unit in North Oxfordshire. It was noted that 7 out of 9 of the obstetrics post had been filled.
• Highlighted the impact that the removal of maternity services would have on South East Oxfordshire with pressure on Wallingford MLU and Stoke Mandeville.

 

The Committee adjourned at 1.35 pm reconvening at 2.30 pm.

 

During discussion the Committee:

 

• noted that they had seen the 2008 IRP judgement;
• was informed by the Chairman that the toolkit referred to by David Smith was not relevant as it was for use to determine if there was a substantial change only when there was doubt;
• expressed some sympathy for the financial constraints the OCCG found themselves working under;
• expressed general agreement to refer maternity services. There was concern that assumptions about extra parking and availability of staff would not materialise and there was no plan to cope with that.
• were concerned about the impact on community based services of bed closures particularly as a means of reducing DToC. More information was needed and concerns were expressed about Phase 2. Recruitment was a problem in Oxfordshire and there were fears that there were no assurances that the additional staff in low paid care jobs would be found.
• Were concerned about the domino effect on services at the HGH and in particular the impact on anaesthetics and A&E services.
• Noted that the responses to concerns raised over the recommendations very often referred to the need to await Phase 2.

 

Following discussion it was proposed by Councillor Fatemian, seconded by Councillor Rooke and as amended by Councillor Price and Councillor Champken-Woods it was:

 

AGREED: (a) to support the proposals for critical care subject to assurances that there will be no knock on effect at the Horton General Hospital;

 

(b) to support proposals for acute stroke services subject to: future guidance on ambulance response times and how it fits with national guidance; and assurances that rehabilitation will be carried out at relevant local sites around the county such as the Horton General Hospital and Witney and Abingdon Community Hospitals;

 

(c) to support the closure of the 110 beds that has already taken place but that they were unable to support any further closures until they had seen the impact of Phase 2 proposals;

 

(d) that whilst agreeing to the principle of the planned care services at Horton General Hospital the Committee were unable to support at this stage as no detailed plans were available and the proposals were not fully thought through, costed and the local community fully engaged in the process. The Committee further considered that although  this proposal could not be considered as requiring urgent decision under Phase 1 they asked that more detailed proposals be brought back with haste to ensure increasing footfall at the Horton General Hospital to ensure sustainability; and

 

(e) to strongly oppose the proposals in respect of maternity services and if the decision is to go ahead with the creation of a single specialist obstetric unit at the John Radcliffe Hospital and to establish a permanent Midwife Led Unit at the Horton General Hospital to refer the matter to the Secretary of State on the grounds that

• This committee has not been adequately consulted;
• The decision is not in the best interests of the residents of Oxfordshire due to the concerns expressed to and by the Committee during the meeting and which includes:
  • The arguments set out in the IRP judgement in 2008 still apply;
  • The fundamental need for obstetric services in Banbury and North Oxfordshire have not changed since that IRP judgement;
  • Increases in population since 2008 and expected further increases impacting on the demand for services;
  • Ongoing issues around access and travel times.

 

The Committee accepted that there were difficulties with staffing, but did not accept that as just cause for the changes when the fundamental needs of mothers had not changed.