Representatives from the Oxfordshire Clinical Commissioning Group (OCCG) and the Oxford University Hospitals Foundation Trust (OUH) will attend to present the report (HHOSC7).
The paper outlines the approach that Oxfordshire Clinical Commissioning Group and Oxford University Hospitals NHS Trust are proposing to take to address the outcome of the referral to the Secretary of State. It is shared in draft form to enable the Joint OSC to ensure the Oxfordshire CCG is covering all aspects and to comment and input before presenting it to the relevant Health Boards for approval.
The paper sets out the scope of the work, an outline timetable and the workstreams that will be established. These include:
· Stakeholder involvement and patient experience - the purpose of this work stream is to ensure that the work is undertaken with stakeholders in an open and transparent way and to seek and use the views of women and families who have used the services since 1 October 2016
· Service description – the purpose of this work stream is to provide the description of the full range of maternity services available to women and their families.
· Interdependencies – the purpose of this work stream is to describe the future vision for the Horton General Hospital and to identify what, if any service interdependencies there are which may be impacted by any decision on provision of obstetric services.
· Activity and Population Modelling – the purpose of this work stream is to collate and analyse activity and develop activity projections that take into account population growth for areas that access services in Oxfordshire.
· Option development and appraisal - the purpose of this work stream is to ensure that all potential options are identified and appraised openly and consistently.
· Addressing Clinical Senate Recommendations - the purpose of this work stream is to ensure that all of the Clinical Senate recommendations have been addressed.
Oxfordshire CCG welcomes comments on any aspects of the plan but in particular would like the Horton Joint HOSC to:
· Agree the scope of the work
· Review and agree the draft engagement plan
· Agree the approach to option development and appraisal
· Agree to the outline timescales
· Identify whether there are any aspects missing from the plan
The Chairman welcomed the following representatives to the meeting:
· Chris Panel – Northamptonshire General Hospital
· Sue Lloyd – Obstetrics/Gynaecology – Northamptonshire General Hospital
· Anne Hargrove – South Warwickshire
· Lou Patten, Sarah Adair, Veronica Miller and Catherine Mountford - Oxfordshire Clinical Commissioning Group
· Kathy Hall and Sarah Randall – Oxford University Hospitals Foundation Trust
Lou Patten gave a brief overview of the situation from the OCCG’s perspective, stressing that Accident & Emergency and Paediatrics services would remain at the Horton and the OCCG was espousing a main focus on planning services, rather than buildings, in order to give a vibrant future for the Horton. The future service planning was linked to a growing population and its growing health and care needs which would lead to, over time, service change at the Horton. She added that, at this meeting, the OCCG intended to share the draft plan and to glean the Joint Committee’s views and comments on the scope of the work and to identify if anything was missing, having learned the lessons from the Secretary of State’s comments in relation to the referral. It was anticipated that there would be monthly updates to the Committee, as well as HOSC meetings, on how work was progressing.
Sarah Adair spoke of the CCG’s plans for stakeholder involvement and a patient experience workstream, to be conducted in an open and transparent way. The CCG would be seeking the views of women and families who had used maternity services across Oxfordshire, including people in north Oxfordshire who had used the obstetric unit at the Horton. These views would be brought into a report to be used in an options appraisal to list the final options.
Veronica Miller stated that a report would be produced describing what maternity services currently look like, to include information from the ten community midwife teams, the four freestanding Midwife-Led Units, the Spires Unit alongside the John Radcliffe Hospital and the main obstetric delivery suite and the tertiary unit at the John Radcliffe Hospital. This would also include information on regional referrals across Oxfordshire, the neo-natal unit at the John Radcliffe Hospital and the transitional care facilities for families. She added that there was close working in place with Warwick Hospital, where mothers were given options for where they wished to deliver their babies. Referrals were accepted from other authorities and a border was shared with Northamptonshire. Sarah Adair added that the paediatric, urgent care team in Accident & Emergency would also be included.
Catherine Mountford added that very detailed information on activity and population modelling had been received and shared, including statistics on, for example, where mothers had given birth and, if the obstetrics service had been needed, where these mothers had come from. Analysis had not yet commenced on information received regarding housing growth for surrounding areas. The CCG aimed to have a full list of all potential options and would work with this Committee to determine the method of appraisal.
Questions asked by members of the Committee and responses received, were as follows:
When asked if the ambitious timescales should be revised, Lou Patten responded that the workstreams would be scoped out in the next four weeks, after which realistic timescales would be determined.
A member expressed his frustration at the need for information and data to support yet another consultation. Lou Patten responded that the IRP had made clear that there was a need for an additional specification focusing on key groups and staffing. Information and data gathered would be added to what was already known.
A member spoke of his concern at the ambulance transfer times from the Horton to the John Radcliffe Hospital, the maximum time of two hours being too long and the range too high. He raised his concern also about how long the temporary ambulance arrangement at the Horton Hospital would be in place. Veronica Miller responded that the Banbury to Oxford and Oxford to Banbury had now been recognised as a good road for travel. Over the last two years there had not been an increase in poor outcomes. The member responded that this statement did not take into account the range of travel time which was 40 minutes to 2 hours, and did not take into account incidents on the road. Also, the temporary arrangement with the Ambulance Trust to keep an ambulance at the Horton in readiness for emergency journeys to Oxford, could be withdrawn at any time. Veronica Miller responded that transfer times were monitored. The focus was on outcomes and over the last two years there had not been an increase in poor outcomes. In response to a question about whether this non-increase could be related to other mothers being diverted to other hospitals, Lou Patten stated that average transfer times would be revisited, together with contingency plans for weather warnings/accidents and where mothers went for alternatives.
A member expressed her concern that the same attention with regard to consultation and engagement was not paid to Northamptonshire residents. The data provided was based on today’s population, but the local plans had been produced up to 2031. Cherwell and South Northamptonshire were aware of population growth up to the next 12 years. Two thousand houses were scheduled to be built in Brackley, some of which had already been built and people were waiting to move in. Population growth is not for the future, it is happening now. Catherine Mountford responded that the CCG was in possession of all the population growth information up to 2031 and what that entailed.
A member commented that the public had to be able to put its trust in this consultation and she was keen for the voices of local people to be heard, as they were the local experts. There was also a need for the whole of Oxfordshire, South Northamptonshire and Warwickshire to be taken into account when considering the number of suites available, to reflect, practically, the number of people who could utilise the units. For example, if there were more births recorded in the Spires birthing Unit, this would affect people from across all the counties. Lou Patten responded that the number of suites in Midwife-Led Units (MLU) would be included. The consultation would have a definite focus on local voices and, in light of the comments today on travel times and contingency planning, these would be reviewed. She wanted to ensure that people were aware that the CCG had a very strong clinical vision for Oxfordshire.
The Chairman stated the importance of the CCG making the distinction between transfer times (in an ambulance) and travel times for a person not in an ambulance.
In response to concern from a member of the Committee, Lou Patten stated that the CCG would consider the impact on the family of extended transfer times and multiple demands on the dedicated ambulance.
A South Warwickshire member expressed his concern about cross-border co-operation between authorities and his belief that this should be looked at nationally. Lou Patten responded that Oxfordshire CCG was keen to ensure that South Warwickshire was appropriately engaged in the options and their analysis. He asked also why there was a recruitment problem at the Horton. Veronica Miller responded that there had been successful recruitment at the Horton, but it was a very competitive market and there was limited opportunity to further careers at the Horton. Staff saw other opportunities and went elsewhere. She added that the retention of doctors had been a problem nationally. Sarah Randall added that OUH would be transparent about rotas and recruitment/retention practices across professions. In response to a further statement that if prospective applicants felt that the Horton offered security of tenure, then perhaps more people would apply there for jobs, Veronica Miller responded that job stability was available to applicants as the terms of contract offered 2 years plus of job tenure. In terms of midwife numbers, Sarah Randall reported that there was currently a shortage of 39 midwives. However, due to the ongoing recruitment campaign, by December it was anticipated that an additional 40 would be coming to Oxfordshire.
A member of the Committee commented on the importance of ensuring west Oxfordshire population housing and growth data was contained within the options, as there was no mention of it in the papers. He also asked the CCG to consider market share, not just market size, for example, to take account of an increased number of births as a proportion of the population (sensitivity analysis). He also advocated the views of the Royal College on the possibility and viability of options. Lou Patten agreed to refine option 4, with market share in mind and to seek the views of the Royal College.
A Committee member asked whether the options presented would give mothers a choice about where to give birth, expressing also a wish to see an assessment of which options were safe. Lou Patten responded that the scoping of each option would include an assessment of safety.
Lou Patten was asked how cost-effective was the transfer of money out if Oxfordshire to neighbouring county trusts; and could it lead to the Horton’s Midwife Led Unit (MLU) being under threat? She replied that money followed the patient and patients exercised their choice. She undertook to share statistics in relation to this. A member asked a further question as to whether the fall in numbers of mothers choosing the Horton was due to concern on their part of a possible two hour journey to Oxford in the event of complications – and would this lack of demand pose a threat to the viability of the MLU? Veronica Miller replied that there was a national drive to establish MLU’s in local environments. She assured the Committee that demand would increase once the future plans were known. Lou Patten added also that there were other people coming to Oxfordshire which helped the figures. She undertook to share the statistics on this matter with the Committee also.
A member made reference to the Shrewsbury & Telford NHS Maternity Unit experience which was currently in the media. Veronica Miller stated that the contributing factors were awaited. She stressed the importance of proper risk assessment and good communication policies between free-standing Midwife -Led Units and Obstetric Units.
The Chairman stated that it was unclear what was in or out of the scope and a detailed look at the survey was required before publication, together with more clarification on the engagement period and the consultation period. He asked if there was any weighting behind the criteria for appraisal of the options. Lou Patten undertook to share the details of the survey and the weighting of options. Moreover, she stated that there would be full transparency on the appraisal process, which was likely to be a two - stage process. She added that the IRP recommendations were about further engagement and the need for consultation would be dependent on the outcome of the options appraisal and engagement.
It was suggested by a member that the CCG might consider accepting views from the public via the ‘Keep the Horton General’ in order to maintain the anonymity of the people giving their opinions. A further suggestion was for mothers to give their evidence via a third party. Lou Patten agreed that this was reasonable and they were welcome to testify before this Committee in this manner.
A further suggestion for the consultation with stakeholders was for the CCG to consider who else they might like to talk to, for example, with future mothers.
A member suggested that the CCG be requested to indicate how the data would be tested and analysed to assess the need in a robust way, including where families had or were being diverted to other hospitals. It also needed to include information on the impact of demand should the Horton become a centre of excellence. In response to a question, Catherine Mountford assured the Committee that the outcome of the work to involve stakeholders in the development of proposals would be taken through the Clinical Senate.
On the conclusion of the questions the Committee AGREED the following:
(a) at a meeting of the joint Committee to be arranged in early/mid-November 2018 the CCG and OUH will share the following:
(i) a more detailed scope for each of the proposed workstreams and a realistic timetable for completion;
(ii) a review of transfer times between the Horton and John Radcliffe Hospitals for mothers needing obstetric interventions and the contingency plans for when there are multiple demands on the dedicated ambulance or severe traffic delays, etc;
(iii) a clinical view on the acceptability of the quoted transfer times (30-120 minutes) from the Horton Hospital to the JR;
(iv) an overview of the data on mothers who have chosen to go to other hospitals because of the situation at the Horton and where those hospitals were;
(v) analysis of the current and future demand for services at the Horton, including an assessment population growth as a result of future housing and growth plans;
(vi) a comprehensive engagement plan that demonstrates a focus on the voices of local people and gives sufficient attention to mothers in Northamptonshire and Warwickshire;
(vii) further refinement of the options (particularly option 4) to take account of the population share of births, as opposed to just the size – i.e. some sensitivity analysis.;
(viii) an overview of the cost of patients going out-of-county vs. the income received from patients coming to the Horton;
(ix) the questions in the proposed survey before this is sent out;
(x) detail about the options appraisal process and any weighting of the appraisal criteria; and
(xi) further information about the approach to recruitment and retention of midwives and doctors at the Horton.
(b) an ‘opinion-evidence gathering meeting’ will be held in December 2018 for the Horton HOSC to hear the views of key stakeholders, the public and interested parties in order to inform the Committee’s future scrutiny of CCG and OUH plans. The Committee agreed to initially invite the following witnesses (this is not an exhaustive list):
· The Local Medical Committee
· District Councils
· Healthwatch (across Oxfordshire, Warwickshire and Northamptonshire)
· Royal Colleges
· NHS England
· Thames Valley Clinical Senate
· Interested professionals (e.g. midwives, obstetric trainee doctors, middle-grade doctors, consultants)
· The Ambulance Service
· Mothers / families who are or have been affected by the loss of obstetric services at the Horton
· Campaign groups