Agenda item

14.20

 

The CCG and OUHFT to report back to the Horton HOSC on the progress with the following:

 

·                Engagement update (Ally Green, Head of Communications)

·                Work on other small units (Sarah Breton, Head of Maternity Commissioning)

·                Finance overview (Catherine Mountford, Director of Governance)

·                Proposed approach to option appraisal (Catherine Mountford, Director of Governance)

·                Current obstetric staffing (Veronica Miller, Clinical Lead for Maternity)

·                Appropriate authorisations and competencies for obstetric trainees (Veronica Miller, Clinical Lead for Maternity)

Prior to consideration of this item the Committee was addressed by Charlotte Bird, from ‘Keep the Horton General’ campaign group (KTHG) who was speaking on behalf of Sophie Hammond also of KTHG.

 

She informed the Committee that investigations carried out by KTHG had found that, despite the information given to this Committee* that hospitals could no longer be registered as a training centre for obstetricians if they had less than 3,500 births per year, this information was false. To date the Group had found other hospitals with births amounting to this figure who were operating with obstetricians. She informed the Committee that KTHG would be offering a paper to the Committee’s next meeting, which would include data on this. It would also be offering viable options for a viable and sustainable unit at the Horton.

 

* At the meeting on 4 July this was corrected to reflect that the information referred to had been given not to this Committee but to a separate meeting at St Marys.

 

The Chairman welcomed the following Health representatives to the Committee:

 

-       Dr Bruno Holthof, Chief Executive, Oxford University Hospitals Foundation Trust (OUH) attending on behalf of Louise Patten, Chief Executive Officer, Oxfordshire Clinical Commissioning Group (OCCG);

-       Veronica Miller, Clinical Director, Maternity, OUH

-       Kathy Hall, Director of Strategy, OUH

-       Catherine Mountford, Director of Governance, OCCG

-       Ally Green – Head of Communications, OCCG

-       Kate Barker, Deputy Director, Strategy & Planning, Northamptonshire CCG (NCCG)

 

Survey

 

Catherine Mountford introduced the report HHOSC6 stating that, in relation to engagement, the largest area to update the Committee on was the survey, which was currently live and open. Ally Green highlighted the following:

 

-       to date 958 women had been surveyed and 450 partners had also completed the section which invited them to give their views;

-       Pragma who had been appointed to run the survey were very pleased with this response to date and hoped to reach a thousand respondees in what was a very lengthy survey;

-       Three focus groups for women to discuss their experiences had been planned, the first of which had taken place that morning in Wantage and there would be two in Banbury.  There had been plans to run a focus group for partners only, but there had been insufficient interest. Instead partners would be involved via a slightly different way which would still be a means of gathering in depth information on their perspective;

-       The second event was taking place in June. Information on these events were available on the front page of the OCCG website in date order to encourage use and to raise awareness.

 

The Chairman asked if there was any information on how many of the people who had responded to the survey lived within the Horton catchment area and how many lived outside of it. Ally Green responded that Pragma was looking at the geographical spread against the baseline and was satisfied that there was a reasonable spread across the geographical area. A member of the Committee stated that some of the invitations had been sent out from GP practices based in South Northamptonshire and Warwickshire. He urged the CCG to ensure that there was a robust response from these areas which would look both ways and similarly from hard to reach areas.  Catherine Mountford responded that they had a catch-up call with Pragma the following week to see if there were any additional areas that they needed to focus on to encourage a response – or even to give additional time to. She extended her thanks to KTHG for promoting the survey. Kate Barker also assured the Committee that they were doing all they could to ensure a good response from South Northamptonshire and South Warwickshire - and had sent the letters out from their GP practices in good time. Ally Green added that PRAGA was monitoring this and, as a result, it had raised concerns about the demographic spread. Fewer Polish and Eastern European communities had responded.  To remedy this the CCG had published advertisements in Polish and had sought the help of community workers in Banbury who had gone out to groups to encourage people to respond. Ally Green added that a website link was also available with screening questions.

 

In response to a question asking if OCCG had a bank of full data, or was everything received added to information which had been gleaned in the past? Ally Green stated that OCCG was not discounting all that had been received over a period of time. She added that the Secretary of State for Health had requested that public opinion be gathered across the area in order for views to be fully understood. Kathy Hall added that OUH had also gathered data on patient experience for various exercises and surveys.

 

Recruitment

 

Veronica Miller introduced this section explaining that the staffing required depended upon the size of the service. The John Radcliffe Hospital was a tertiary centre, looking at complex foetal medicine. 15 doctors who were starting out on their training were required, but only 12 were in post. She also highlighted the complexity of this, due to factors such as maternity leave etc. and it rotated frequently. She added that qualified doctors in training had to pass core competencies for the additional skills that were required to do the job. Doctors who had reached year 4 and above were competent to work alone. As they became more experienced by the end of 7 years, they were exposed to more complex cases and thus received more training and additional experience. At the end of year 6 – 7 they undertook specialist training and focused on becoming specialist consultants, which took a further 2 years.  Some became specialist consultants, some general consultants. Gynaecology specialists, were requested to attend certain sessions which were speciality – based. Thus, if one was looking at different models of how to run these services there was a need to look at different tiers of staffing. Rules had changed, and doctors no longer undertook shift patterns of the past. The rules for new doctors specified that they had to be compliant with junior doctor conditions of service. This was different for trust grade doctors. Kathy Hall added that workforce modelling would be included as part of the assessment of all options. She told the Committee that the rules had changed since 2016 to ensure compliance with junior doctors’ service. Terms and Conditions of Service were expected to be followed.

 

Comments and questions from Members, and responses received, were as follows:

 

-       A member commented that the IRP advice given in 2018, stipulated that 7 doctors were needed, to the required 9 and currently there were 2 in post, asking what had happened to the other five? – Veronica Miller explained that this accorded with the drop-out rate nationally, which amounted to a 30% attrition rate. The Royal College of Gynaecology had opened up another entrance level to the profession at stages 3 and 4. This had led to some doctors entering the national trainee scheme at stage 4. Of these, most had taken up consultant posts elsewhere. Also, some had already been working their notice. Kathy Hall pointed out that this breakdown had been provided in a previous paper – and offered to circulate it again.

-        A member made a plea to start with a clean sheet, which would very helpful as it was easy to build in a set of assumptions. In a short time, the Committee would be looking at a set of options, together with models and practices elsewhere and innovative practice required a fresh approach. In this respect, it was also important for the Committee to understand the details of different models and practices elsewhere, in relation to clinical viability. This would include, for example, practices at Harrogate and Lancaster;

-       A member commented that it had proved helpful to use clinical research fellows as a temporary plugging solution from 2012 for 3 to 4 years. In response to a question about whether this particular option was totally dead, Veronica Miller stated that the option of running solely on clinical fellows had been taken off, adding that no details of this were available as they related to the running of academic programmes. However, staffing was being looked at, and different health specialities were also under investigation. She emphasised that this option was not being discounted totally, but in reality, with the numbers in question, running it exclusively with clinical research fellows was not a robust way of managing it. She added that it was also too difficult to find sufficient numbers of people of the required calibre.

 

Financial Analysis

 

Catherine Mountford, in introducing this section of the report, pointed out that the OCCG had both looked at, and noted, that they and OUH had erroneously provided tables showing differing calendar and financial years.

 

A member commented that valuable data from current and previous years was missing which would have provided a comparison with which to study how far birth rates had dropped and the associated decline in income for the Trust. This had been asked for at a number of occasions by this Committee. Catherine Mountford agreed that there was a need to provide historical information in relation to the commissioning spend for the same period.  She undertook to bring those workstreams together for the next meeting of Committee. She clarified that OCCG had presented the Committee with information as the work, based on current activity flows, had been completed on catchment populations and housing growth.

 

Kathy Hall added that there was a need to show the Committee the difference between specific services in order to give a more complete picture. This would include a breakdown of all the figures.

 

Dr Holthof stated that OUH wanted to provide an excellent service regardless of the money, adding that skilled professionals across all services in Oxfordshire had a tough time in Oxfordshire. The biggest challenge was how to ensure that enough patients were treated, with insufficient numbers of staff to do so. A member commented that the Committee still needed to be convinced that efforts were being made to make maternity services more attractive at the Horton, for women to feel that they wanted to give birth there.

 

Option Appraisal Process

 

Catherine Mountford, in introducing this section of the report which outlined the option appraisal process, emphasised that CCG wanted this to be as open and transparent as possible. She added that weighted scorings would not be the only part of the decision, an engagement exercise would also be undertaken on a written proposal and recommendation. She asked if the Committee would like to look at the engagement exercise.

 

A member enquired why would the scoring exercise be undertaken without a decision on the weightings? Ally Green explained that the weighting had already been completed at the first stakeholder event. The scorings would be collated by an external team and the weightings would be applied afterwards.

 

A member put forward the view that the manner in which the weighting was determined would then determine the outcome. Catherine Mountford responded that this was the reason why stakeholders were involved in the weighting activity, and OCCG and OUH had not taken part in the activity. Kathy Hall added that this process was based on good practice.

 

Whilst the Committee agreed with the concept of separating the weighting from the scoring, it felt that this was rife with potential problems, such as it being an invisible process. Somebody had to judge on the process of deciding which was important, how it compared with the others and then to make judgements – and this was not a mechanical art. Judgement would then have to be made on whatever was decided made sense. It also depended upon who put the evidence and data together, there being issues of nuance. It was suggested that this should not be the only process.

 

Dr Holthof also agreed that whilst separation was good, the weighting process should be both visible and transparent in order to give more confidence on the scoring. Moreover, the weighting would impact on the overall assessment of options. There was thus a need to take another look at the process and on how to resolve the influencing of the weighting. Catherine Mountford AGREED to take it away to look at the process and how to share with, and involve the Committee in it. There were 13 categories. She AGREED at the request of the Chairman, that once it had been decided about how the weighting process would be undertaken, then this would be shared with the Head of Legal at OCC, Mr Nick Graham, in order to keep the integrity of the process.

 

The Committee then AGREED to request Sam Shepherd to seek independent advice on the feasibility and costs of appointing a consultant to ???????SAM NOT SURE THIS WAS AGREED IN THE END???

 

With regard to the transparency of the evidence and the scoring, Catherine Mountford reported that these would be published and taken to the stakeholder event and then to the next meeting of this Committee. This would be presented in a formative stage prior to their submission to NHSE to undergo the assurance process. The Chairman requested that there be a transparency about the process, as the Committee had substantial concerns about the option appraisal process. Catherine Mountford responded that the option appraisal was important but was not the only part of the process.

 

A member asked why the scoring panel had not included any clinical input, to which Catherine Mountford stated that this could be considered as part of the assurance process.

 

The Chairman stated that a significant amount of work was to be provided at the June meeting, and, in light of the need for this information to be more substantive, he advised Health representatives to consider the 24 June date to be provisional only. There was a strong possibility that the meeting would take place during early to mid - July in order to give sufficient time for a fuller and frank discussion.

 

Dr Holthof was asked by the Chairman whether he could honestly say that the quality of service provision for women giving birth at the Horton was improved by not having an Obstetric service? He responded that OUH took all decisions on the principles of quality and safety, adding that it was not about money. The Trust wanted to provide a safe service and this was the biggest concern for staff. Veronica Miller added that if the Trust had continued with the numbers of doctors it had, it would have been an unsafe service and a worsened patient experience. Catherine Mountford quoted the three elements of quality as defined by national NHS for quality outcomes which were clinical effectiveness, safety and patient experience.

 

A member asked if the process of doing the options analysis and the weighting would be fruitless if the workforce options were not sustainable? Kathy Hall responded that the Trust felt it was important to look at the different workforce models to see if there were different ways of doing it.

 

In response to a question, Kathy Hall confirmed that the options would involve multiple sites. Dr Holthof re-iterated that safety trumped everything else – and it was therefore important that agreement was reached on the options and weighting processes, as money would not enter into it. If safety could be guaranteed, then other options would be looked, if not, then the service at the Horton could not be provided.

 

The Chairman thanked all for attending.