Minutes of the High Weald Lewes Havens Clinical Commissioning Group extraordinary formal Governing Body meeting held in public on Wednesday 11 December 2013 from 1pm at Lewes Sports Club, Kingston Road, Lewes, BN7 3NB Members Dr Elizabeth Gill Dr Peter Birtles Karen Ford Alan Keys Denise Matthams Dr Neil Myers Frank Powell Dr Sarah Richards Dr David Roche Dr Michael Rymer Michael Schofield Frank Sims Dr Howard Wright Clinical Chair (EG) Clinical Lead for Urgent Care (PB) Lewes Havens Locality Practice Management Lead (KF) Lay member Patient and Public Involvement (AK) Registered Nurse member (DM) Planned Care Clinical Programme Lead (NM) High Weald Locality Practice Management Lead (FP) Chief of Clinical Quality and Performance (SR) High Weald Locality Chair (DR) Secondary Care Clinician (MR) Chief Finance Officer (MS) Chief Officer (FS) Lewes Havens Locality Chair (HW) Attendees Wendy Carberry Head of Delivery (WC) Amisha Koria Senior Communications Manager (AK) Hugo Luck Corporate Development Manager (HL) Katie Merrien Corporate Services Manager (KM) (minutes) Ashley Scarff Head of Commissioning and Strategy (AS) Claire Turner Consultant in Public Health, East Sussex County Council (CT) Members of the public Questions from the public were taken prior to the formal opening of the Governing Body meeting. A record of the discussions can be found in Appendix A. 1/13 Welcome and apologies for absence The Chair welcomed everyone to the meeting, and highlighted the importance of the discussions which would be taking place that day. Apologies were received from Peter Douglas, Lay member for Governance and Vice Chair. 2/13 Declarations of Interest There were no declarations of interest prejudicial to any agenda items. 3/13 Maternity and Paediatrics; proposed future delivery options David Roche, HWLH CCG s lead for Maternity and Paediatrics, outlined the process undertaken to date; which was included in the draft Pre-Consultation Business Case (PCBC) submitted to the Governing Body for discussion. David Roche highlighted that East Sussex had a long history of quality and safety issues in Maternity services; which had yet to improve, despite significant investment. It was noted that, since the Maternity services review in 2006/7, providers and commissioners had undertaken a high level of work to try and improve services; which had included the formation of Sussex Together as recognition that any decisions would impact on neighbouring organisations. Action David Roche explained the lead GPs across Sussex had written a Clinical Consensus for safe services, which the Governing Bodies had signed off earlier in 2013. It was noted that the CCGs senior GPs had developed the models of care;
which had subsequently been tested against the Clinical Consensus, to ensure they were appropriate for the required service. All three CCGs in East Sussex had then supported the single-siting of obstetrics, David Roche noted that, whilst Gynaecology had not been discussed by Sussex Together, it had been included in the developed models of care. David Roche reported working groups had been established to measure the 30 possible delivery options against the models of care, to discount any options that could not deliver the required service. Assurance was given that the working groups had thoroughly explored whether fully-staffed, consultant-led obstetric units could be maintained on two sites, including talking to units elsewhere in the country about their experiences, but had found there were no possible delivery models which would deliver safe and sustainable services on two sites. The review had resulted in only six options remaining, all of which would meet the models of care and could deliver a sustainable and safe service. David Roche explained that, subject to the Governing Bodies agreement of the options, they would be submitted to the HOSC for consideration at a meeting that will be in public on 10 th January 2014; where the HOSC would declare whether the proposed options were a significant change and therefore required to go to public consultation from 13 January 2014. Ashley Scarff confirmed the CCGs would then review the feedback from the consultation, complete an Options Appraisal, and make a recommendation for the preferred delivery option as part of a full business case (FBC). Action: David Roche agreed to ask Dee Coffey, Programme Manager for Maternity and Paediatrics, to confirm if an impact assessment had been completed for the potential increase in deliveries at Brighton and Sussex University Hospitals Trust (BSUH), Maidstone and Tunbridge Wells NHS Trust (MTW) and Princess Royal Hospital (PRH). DR 22/1/13 Ashley Scarff gave assurance that dialogues with other providers were underway about potential increases in deliveries, and confirmed other Trusts would be invited to respond to the options being considered. David Roche noted impact assessment data would be included in the discussion about the siting of services. Assurance was given that the review of admissions had looked at a significant amount of background data beyond the details in the report. David Roche gave assurance that access analysis for individual patient groups would be contained in the Full Business Case; including details of the number of non-uk residents who did not speak English as their first language, which contained a particular risk within obstetrics. Michael Rymer proposed consideration should be given to Gynaecology services being extended to 7 days a week instead of 5, to reduce pregnancy-related emergency admissions such as miscarriages. Action: David Roche agreed to ask Dee Coffey to ensure the FBC included details of the number of patients booked in to deliver at Midwife-Led Units (MLUs), and not just the number of deliveries which had occurred, so the CCGs could review the number of transfers in labour due to other factors. Action: David Roche agreed to confirm whether the establishment of a dedicated Children s A&E Unit had been considered within the process to date; as it was a requirement for any sites which treated over 14,000 children. DR 22/1/13 DR 22/1/13 Concern was that Crowborough Hospital was currently seen to be the weak link in Maternity services; especially since ESHT had stopped providing an obstetric 2
ultrasound service, due to issues with recruiting an ultrasonographer. Alan Keys highlighted that the public and the CCG wanted Crowborough Hospital to be given fair consideration during the process, without opinion being based on services as they currently stood. Frank Powell noted concern that, following ESHT s recent closures of the birthing unit and Minor Injuries Unit (MIU) in Crowborough, the Trust would strategically manage Crowborough in order to get the results it wanted from the consultation period. The Chair gave assurance that the CCG had taken ESHT s contract breaches very seriously, and had imposed the associated contract levers and are to meet with the Trust s Chair and Chief Executive to discuss its concerns. Alan Keys highlighted the need to understand the reasons behind the reduced number of births at Crowborough, such as the previous issues with midwives at Uckfield Hospital referring patients to Haywards Heath instead of Crowborough. David Roche confirmed GPs could encourage the public to visit Crowborough, once the consultation had been completed. Peter Birtles noted the decline in deliveries at Crowborough was also a result of the new Maternity unit at Pembury Hospital, which had more modern equipment and facilities. The Governing Body discussed the importance of discussing where the units would be best placed before reviewing the additional services required in other locations to support service delivery, such as robust neonatal scanning, but noted the importance of also understanding any issues around patient flows. The Governing Body agreed HWLH CCG would begin a review to determine whether any other services based at Crowborough Hospital could be increased, such as the use of scanning services to support services beyond anti-natal care, to support the CCG s strategy to move maximum services into the community. Peter Birtles reported the services at Crowborough had previously attracted women from across the south of England, and from France. David Roche gave assurance that there were other providers who would be interested in providing services at Crowborough, so future services would not necessarily be delivered by ESHT. Frank Powell stated HWLH CCG and its patients would not want to support the two options which excluded retaining services at Crowborough. Frank Sims highlighted that Eastbourne, Hailsham and Seaford (EHS) CCG and Hastings and Rother (H&R) CCG were also part of the conversation; and there were options which proposed the removal of obstetrics services from their areas too. Frank Sims stated it was each CCG s duty to make the best decision for its population. Assurance was given that the case for change was being driven by the need to establish safe and sustainable services, and not by the intention to save money. Sarah Richards highlighted the previous issues at Eastbourne District General Hospital (EDGH) regarding the recruitment of middle-grade doctors would not be resolved by returning to the previous set-up; which was why changes needed to be made to ensure services were safe. David Roche gave assurance that the CCGs decision was not be based on ESHT continuing to run Crowborough Hospital, so there was no need for concern that ESHT would try and save money by closing the birthing unit at Crowborough Hospital. Michael Rymer reported local obstetricians options continued to fluctuate between co-located MLUs and obstetric units, and different locations for each service; but there was unanimous agreement of the importance of safe services. Ashley Scarff added that local obstetricians have confirmed the standards of care required by the CCGs could be achieved in both co-located services and stand-alone MLUs. It was noted the Royal College of Obstetricians had supported the co-location of services, but had also recognised the benefits of stand-alone services. Frank Sims noted women would decide for themselves on whether to go to co-located or stand-alone services, based on their own preferences. 3
3/13 (i) Agreement on the proposed future delivery options for Maternity and Paediatrics to go forward to the Health Overview and Scrutiny Committee (HOSC) for consideration regarding formal public consultation The Governing Body agreed unanimously that the proposed future delivery options for Maternity and Paediatrics would go forward to the HOSC for consideration regarding formal public consultation. 4/13 The future provision of NHS Beds for the admission and assessment of people with dementia. The Chair noted the prevalence of dementia, to the current G8 summit taking place, and the Prime Minister s selection of dementia as a key priority. The Chair gave assurance that HWLH CCG wanted a high standard integrated care pathway for dementia, and intended to work with practices to identify dementia earlier so it could be prevented. Ashley Scarff reported all three CCGs in East Sussex currently commissioned two units for dementia through Sussex Partnership Foundation Trust (SPFT), and explained that the need to review dementia bed provision had stemmed from the fact that only 54% of ward beds were being occupied. It was noted the reduced demand for capacity had been caused by a number of factors including increased capacity for other diagnoses, and the introduction of respite breaks for carers. Ashley Scarff explained Option 1, recommending no change, was not recommended because it would continue to maintain excess beds, and the current wards physical footprint did not support the modern delivery of services CCGs wanted for their patients, given that dementia was often accompanied by other morbidities which require additional treatments. Ashley Scarff reported Option 2 was not recommended because it would move services into a less than ideal clinical environment, and did not support the critical clinical mass for good quality care, due to being a smaller number of patients. Ashley Scarff explained Option 3 was not recommended because of the high anticipated capital costs required to adapt the current layout of one of the existing sites, in order to provide for all patients. Ashley Scarff gave assurance that the recommendation of Option 4 had come out of a detailed Options Appraisal, where it had scored highest due to recognising the potential of creating a better model of care. This tied in with the opportunity to work with stakeholders to look at current issues and inform the development of new services, and gave the opportunity for care closer to home; in line with the CCG s strategy. It was noted SPFT had also informed the CCGs that the current financial landscape would be affected by its contract rebasing; which would therefore be reviewed alongside the models of care. Ashley Scarff confirmed several potential locations had been identified, to support the intended agreement of Option 4; but explained the agreement of the model of care would need to predicate the selection of a site. Ashley Scarff noted the CCGs clinicians had met in parallel to the public consultation, to begin the review of best practice for dementia provision. Assurance was given that, if Option 4 was agreed, an Outline Business Case (OBC) which contained tested, budgeted, evaluated options, informed by the new model of care, would be submitted to the Governing Bodies for approval. Ashley Scarff explained the CCGs initial intention to review the use of resources in order to make savings had shifted since the engagement process, due to the receipt of further information about the public s requirements for services. Assurance was given that SPFT was not trying to procure an unnecessary new unit, but that the 4
proposed option was intended to provide the model of care that the CCGs wanted. Ashley Scarff noted the CCGs would probably develop an existing building somewhere in the county, rather than building a whole new unit. The Chair gave assurance that the new model of care would be designed to pick up dementia in the earlier stages, supported by a new scanning tool which was able to detect dementia before symptoms began to show; thereby reducing the need for crisis beds, despite the projected increase in future dementia rates. It was noted that the current issues with delays in outreach services could also be addressed by running training sessions in nursing homes, to help them cope with crisis patients and therefore prevent emergency admissions. Ashley Scarff gave assurance that the risks associated with longer travel times and access for patients and relatives would be factored into the conversation about suitable locations for the new unit, and highlighted the need to consider whether this would be a co-located or stand-alone site; because this would impact the potential siting options. Claire Turner highlighted that the new model could aim to keep patients at home or closer to home, thereby negating some issues with transport and decreasing recovery rates; as patients entering in-patient settings took longer to recover. The Governing Body noted the importance of establishing good outreach services in order to support the longer travel times. The Chair highlighted the importance of not becoming attached to the current buildings, and thinking objectively about the desired outcomes and required access to other services, such as diagnostics and CT scanning, when making the decision. Ashley Scarff gave assurance that the CCGs intended to improve the management of the fluctuating dependency of patients in dementia beds, to prevent a repetition of the previous temporary closure of the Beechwood unit to new admissions, due to the high dependency of patients already in the unit. The Chair noted the current need for the Beechwood unit was rare, due to the robustness of the community services available to treat patients at home. Frank Sims noted the consultation had emphasised the importance of listening to the public and conducting detailed reviews of service activity and finances; as the CCGs had reached a very different solution than anticipated. The Chair stated the process had highlighted the importance of reviewing patients experience of entire pathways prior to deciding what was required from a service to be commissioned. Ashley Scarff explained SPFT s requested change to a bed-based currency contract, and the associated risks, would have happened regardless of the consultation being undertaken. Frank Powell noted concern that block contracts incentivised providers to keep beds unoccupied; so a change in the SPFT contract could cause an increase in bed days. Ashley Scarff gave assurance that any concerns of the CCGs would be raised in the contracts dialogue with SPFT. Frank Sims highlighted the CCGs would need to be clear with SPFT that the savings originally intended to come out of the dementia beds review would now need to be found elsewhere in SPFT s baseline contract. Michael Schofield noted that the move from a block contract with SPFT would need to be undertaken across all services within the contract; which could expose other areas for the commissioners to review to find the required savings. The Chair explained any potential savings would be made by aligning the model of care with the CCG s Clinical Strategy, in order to reduce unscheduled care. Alan Keys proposed that, should any savings be made after implementing a revised model of care, the funding was used to improve carers quality of life. Ashley Scarff explained Option 4 was being recommended to enable the CCGs to make a decision about the new pathway first; as there were a number of options 5
and models of care which required thorough testing first. Assurance was given that best practice for dementia was currently being evaluated, and the new model of care would be clinically agreed and provide a better service. It was noted the developed models of care would include input from Secondary Care consultations and psychologists, and would also take into account the 80% of dementia patients with other long-term conditions. Denise Matthams requested that the pathway included an evaluation of the average time patients spent in each part of the pathway. Ashley Scarff gave assurance that the phrasing of Option 4, which stated both sites would be closed and a wholly new model of care developed, did not mean the sites would close before the new model of care was ready to be implemented; with current services expected to remain until the new service was ready. It was confirmed that none of the existing beds would be closed until a new model had been agreed. It was noted Option 5 was not recommended, despite almost equal scoring from the Options Appraisal as Options 4 and 4a, because consolidating beds onto one site whilst services were redefined would be a very difficult process. It was agreed that both existing sites should be retained until the new service was ready, regardless of the expense of maintaining two sites, because moving patients more than once would cause additional upset and disruption. The Governing Body agreed the two existing sites should not be excluded from the options considered when the CCGs looked to identify a suitable new location for new model services. 4/13 (i) Agreement on the preferred option for implementation following the dementia assessment beds consultation. The Governing Body agreed unanimously that Option 4 was the preferred option for implementation, with the caveats that the model of care was subject to a FBC process, including Governing Body sign off, prior to the closure of the existing sites, and that neither of the existing sites was precluded from consideration when identifying the future location for the new model of care. Dates of future meetings: 1pm, 22 January 2014, Meeting Room 1, The Crowborough Centre, Pine Grove, Crowborough, TN6 1FE 1pm, Wednesday 26 March 2014 (venue to be confirmed) 1pm, Wednesday 28 May 2014 (venue to be confirmed) 1pm, Wednesday 23 July 2014 (venue to be confirmed) 1pm, Wednesday 24 September 2014 (venue to be confirmed) 1pm, Wednesday 26 November 2014 (venue to be confirmed) The meeting closed at 2.30pm. Freedom of Information Act: Those present at the meeting should be aware that their names and designation will be listed in the minutes of this Meeting which may be released to members of the public on request. 6
Appendix A Questions asked at the meeting by members of the public. 1. Richard Hallett, from the Friends of Crowborough Hospital, asked about the Maternity feedback from High Weald service users which had been received by the CCG s engagement team. Mr Hallett stated there had been strong feedback in High Weald about the serious disconnect in Maternity pathways between the community midwifery services provided by East Sussex Healthcare NHS Trust (ESHT) and local scanning and obstetrics available "out of trust" from other providers. Mr Hallett reported that, since obstetrics had closed at Eastbourne, the booking numbers for GP Practices at Saxonbury, Beacon, Wadhurst, Mayfield, Brook, Forest Row and Groombridge showed 86% of women were booking at Maidstone and Tunbridge Wells NHS Trust (MTW) to avoid being sent to the South Coast for their scans and avoid the risk of being referred to consultant care at Hastings. Mr Hallett stated this had created a big disconnect in antenatal maternity pathways, and had fragmented what was supposed to be a joined-up service. Mr Hallett asked why the feedback, which had also been supported by the Health Overview and Scrutiny Committee (HOSC), had not been accounted for in the options provided, and stated High Weald women wanted community midwives to come from local obstetric providers; in line with the existing arrangements in Lewes which gave a locally accessible, joined-up pathway. Mr Hallett stated he felt that the given options appeared to represent the prejudicial exclusion of women from High Weald, which therefore compromised the validity of that part of the conversation. David Roche gave assurance that the Governing Body s discussion would relate to the best physical siting of obstetric units, but would not predicate providers or pathways because they were still to be determined. David Roche confirmed HWLH CCG was aware of the feedback from women in High Weald, and gave assurance it would be taken into account in the final decision-making process. Frank Sims highlighted the CCG recognised the majority of pregnant women in HWLH did not necessarily use ESHT s birthing services, and confirmed this would be included in future conversations about the service. 7