|Consideration was given to a report that presented consultation proposals relating to Critical Care and Emergency Medicine at North Tees and Hartlepool NHS Foundation Trust. In line with the statutory regulations, arrangements had been made to establish a separate Joint Health Scrutiny Committee in order to respond to the consultation.|
The Joint Health Scrutiny Committee would be meeting on 11 July 2013 to consider the proposals and take evidence from key stakeholders. A further update was be presented to the Council meeting, comprising Stockton's proposed views and comments in relation to the consultation, thereby enabling Council Members to agree the Council's representations and submission for inclusion in the Joint Committee's response to the consultation.
At the request of Hartlepool and Stockton-on-Tees CCG, the National Clinical Advisory Team (NCAT) had undertaken a review of the provision of Critical Care and Emergency Medical services within North Tees and Hartlepool NHS Foundation Trust.
The NCAT review advised on the configuration of services in the lead up to the completion of the planned single-site hospital at Wynyard. The NCAT Final Report was published on 15 May.
In line with the NCAT recommendations, the CCG had entered into a period of public consultation between 20 May and 11 August on proposals to reconfigure the services under review.
The public consultation document stated that, after much discussion with health professionals, a review of alternative options and receiving the report from the independent National Clinical Advisory Team, which agreed that there were no viable safe alternatives, it was proposed to centralise emergency medical and critical care services at the University Hospital of North Tees from October 2013.
Public consultation was being undertaken by Hartlepool and Stockton-on-Tees CCG, in partnership with Durham Dales, Easington and Sedgefield (DDES) CCG, and North Tees and Hartlepool NHS Foundation Trust.
The public consultation document stated that the Trust would:-
"open 120 beds at the University Hospital of North Tees to make sure we have enough beds and staff to look after patients from right across our area
make extra space in critical care so we can look after critically ill patients
then, gradually, close the beds in medicine and critical care at the University Hospital of Hartlepool
and transfer a number of staff from support services such as pharmacy, radiology and pharmacy and estates that need to come to the University Hospital of North Tees to support the new arrangements"
The proposals also included the potential for additional elective and rehabilitation services at the University Hospital of Hartlepool.
Further detail on the public consultation process could be accessed via:-
The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 required the formation of a joint scrutiny arrangement when an NHS body or relevant health service provider consulted more than one local authority on proposals to make substantial variations or developments to services. They provided that all the local authorities whose residents were affected and that considered the matter to be a substantial variation to local health services, must participate in the joint scrutiny arrangement for the purpose of responding to the consultation.
In such situations it was only the Joint Committee that could not require the organisation proposing the change to provide information to them, or attend before them to answer questions. If a local authority had opted out of the joint arrangement, they may not request information or attendance from the NHS body or relevant health service provider proposing the change.
In scrutinising the proposals, the Joint Committee should aim to consider the proposal from the perspectives of all those affected or potentially affected by that proposal.
On this basis, Stockton-on-Tees, Hartlepool and Durham Councils had established a Joint Committee for the purposes of responding to the Critical Care and Emergency Medicine consultation.
The Joint Health Scrutiny Committee met on 11 July 2013 to consider the consultation proposals and take evidence from key stakeholders. A further meeting of the Joint Committee would take place on Monday 29 July to agree the final consultation response from the Joint Health Scrutiny Committee (which would incorporate Stockton Council's response).
A copy of Stockton's Draft Response to Consultation on Reconfiguration of Critical Care and Emergency Medicine was presented to Members as follows:-
"Quality and safety
1. It is accepted that the proposals to bring together critical care and emergency medicine on one site are clinically led, and have the potential to improve outcomes for patients from across the geographical area covered by the Trust. The preferred long term solution for hospital services in the North of Tees area remains the development of the new Wynyard hospital, however it is recognised that the Clinical Commissioning Group (CCG) and North Tees and Hartlepool NHS Foundation Trust must address the situation as it currently stands to ensure that services are safe and of high quality.
2. The main concerns are with the sustainability of the critical care unit at University Hospital of Hartlepool due to under-utilisation, difficulty in staffing, and its small size, which taken together mean that the unit is in danger of failing to meet the clinical standards required. These standards are continually developing, as critical care becomes a speciality in its own right, rather than a sub-set of anaesthetics. Emergency (or acute) medicine must be co-located with critical care and therefore the proposals have a wider impact. There are also opportunities to improve emergency medicine through a combined approach.
3. Continuing with the two site approach to critical care in particular raises a number of risks that will build over time. These include unnecessarily delayed diagnosis and therefore poorer outcomes, a detrimental effect on training opportunities, and an increasing need for transfers of critically ill patients.
4. A one site approach would mean patients have access to all the potential services they require at the first point of contact.
5. The different levels of service between the two sites are already apparent (for example routine tracheostomy can only be performed at certain times of the day at Hartlepool). This already creates an inequitable situation for patients, and the risk is that their outcomes become simply dependent on which hospital they are admitted to.
6. Due to the ever increasing specialisation of critical care, and the lower usage of the unit at Hartlepool, recruitment of anaesthetists is an issue. A combined critical care unit will be a more attractive option for trainees and provide a safer environment.
7. The centralisation of emergency medicine will enable the Trust to work towards having an increased range of specialists available around the clock, which will enable specialist input into a patient's care at an earlier stage than may be possible at present.
8. As the field of emergency medicine becomes increasingly specialised, Stockton representatives agree that there is a need to continually work towards having the right clinicians, in the right numbers, and in the right specialities, in order to cover the range of conditions that patients present with.
9. It is pleasing to note that recruitment in the emergency medicine department remains strong, and high quality candidates are seeking to work at the Trust, particularly in elderly care.
10. Ultimately, it would be unacceptable for a relatively small geographical area as covered by the Trust to have two units providing different levels of care. Therefore the proposal to concentrate these units on one site is strongly supported.
11. The proposals have been supported by the independent National Clinical Advisory Team (NCAT) following its review in January, and this was re-affirmed through its additional submission submitted to the Joint Committee.
12. The Joint Committee was informed that the Trust was being commissioned, separately to the proposals under consideration, to provide an additional 24 bed unit at North Tees to cope with winter pressures. This is to be welcomed in light of the recent experience of the NHS, and also due to the fact that, as a result of the proposals, the total number of beds at the Trust as a whole will go down from 598 to 585.
13. The options process appraisal as described to the Joint Committee included consideration as to which site should be chosen, once the proposal to concentrate these services on one site had been agreed. North Tees was selected as it is the site for complex surgery and trauma, other related clinical and support facilities, and has the necessary space required.
14. It should also be noted that, even if it was possible to separate these services from those they inter-link with at North Tees and fit them into the current layout of the Hartlepool site (and Members were informed it was not), this would have led to twice the disruption in terms of movement of beds and people, including staff.
15. There is also the issue of population and geography. North Tees Hospital is situated in the north of Stockton Borough, which has a population of c.192,406, compared to Hartlepool's population of 92,238 (ONS Mid-2012 population estimates). Therefore if the principle of combined units is accepted, it makes sense to locate them nearest to the greatest number of people. North Tees is also accessible for patients who are resident in the Sedgefield area of County Durham. Clearly transport is a key issue for all those affected, and this is addressed below.
16. The Joint Committee was reassured that the University Hospital of Hartlepool site will continue to be a centre for planned (elective) care, including orthopaedics and breast surgery for lower risk patients. This is crucial for the Trust as a whole as there is not enough capacity at the North Tees operating theatres to undertake all the surgical activity required.
17. On that basis it should be noted that already a number of Stockton Borough residents travel to Hartlepool, and there is the potential for this to increase once the detail of some shift in elective care from North Tees to Hartlepool is more fully described. Based on 2012-13 activity, 817 Stockton residents had elective care at Hartlepool (nb. it is assumed that of these 57 were higher risk patients who in future would be cared for at North Tees, as outlined above). Any increase in the number of Stockton residents having treatment at Hartlepool will need to be considered closely, including any impact on residents at risk of social exclusion through disability, those who require longer stays, and the consequent impact on visitors.
18. It will be key to the success of the elective centre at Hartlepool, and the safety of patients from all Boroughs, that the remaining clinical support team at that site is appropriately resourced (as noted by NCAT) and that the risk stratification process to determine whether a patient is low or high risk is as robust as possible.
19. Overall the proposals will mean 100 acute medical beds and 4 critical care beds will transfer to North Tees, which in terms of patient activity equates to 10,806 admissions a year (in total across all CCGs affected), based on 2012-13 activity levels. This means an additional 30 patients per day will receive their treatment at North Tees.
20. It should be noted that these figures include 284 emergency and ambulatory patients from Stockton who will be cared for at North Tees rather than Hartlepool in future.
21. In addition approximately 200 staff would be affected. Taken together with the numbers of visitors that can be expected, this clearly represents a significant number of people at the North Tees site.
22. Transport and access is a key concern in relation to any proposed change to health services, particularly for areas of low income and low car ownership. Visitors play a key part in the recovery of patients and will obviously be concerned about the condition of their relatives and friends.
23. The Joint Committee heard examples from Healthwatch of the stress placed on people in emergency situations when trying to visit relatives without access to cars. Examples were also provided of the difficulties in relation to attending early morning appointments that were difficult to attend using public transport, and also in some cases, using NHS Patient Transport due to its operating hours.
24. People with low incomes may qualify to claim back the costs of travel to health appointments, but this is on the basis of those people having had the money in the first place to spend; this is becoming increasingly hard for many people.
25. These are real concerns, and the CCG and Trust have both committed to working in partnership with local authorities, and Healthwatch, to tackle this issue which will affect patients from all areas, and this is to be welcomed.
26. In terms of initial patient access for emergency and urgent care, this will mainly continue as at present, with referrals via GPs, NHS111 or 999. The North East Ambulance Service was unable to be present at the Joint Committee but have indicated that they will work with the CCG and Trust to understand the impact on the overall capacity of the Service locally.
27. In terms of scheduled transport needs, the Trust has brought forward a number of suggestions. These include the provision of two 17-seater shuttle buses which will operate from summer 2013, on a seven-day a week basis, between 8am and 8pm. These will be operate between the two sites and will be available to the public and staff, free of charge. A staff car sharing scheme is also to be promoted in the summer, and the Trust retains its own same day' ambulances.
28. At the meeting, the Trust gave particular emphasis to the use of volunteer drivers. This would be a service delivered to patients that did not require an ambulance, but needed some assistance with transport. Volunteers are to be commended for their work and this scheme can play an important part in the mix of transport options. However, it is not appropriate or sustainable to develop a major part of the transport solution on the basis of volunteer provision.
29. If this is a perception, it must be addressed. Patients, families and carers should be provided with the full range of transport options. Consideration could be given to building on the example of Durham County Council's Travel Response Centre; this is set up to manage bookings onto a variety of health transport options as part of its work, including Patient Transport, the East Durham Hospital Link Service, and in some cases taxis and volunteer drivers.
30. As was noted at the Joint Committee, there are congestion issues already between Stockton, Hartlepool and County Durham at peak times. Junction improvements are planned for the A19-A689 interchange, however these have not yet taken place and the proposals under consideration may come into force within months. Therefore it is understandable that this adds to residents' concerns, and transport issues need to be considered in the round by the Trust, all local authorities, and transport providers.
31. These issues will need addressing, although overall it is recognised that the major transport concerns lie with residents of Hartlepool and County Durham. However Stockton would need issues to be addressed in relation to the situation of North Tees and the Hardwick area. In particular, the impact of increased numbers of staff, patients and visitors to the University Hospital of North Tees site is a concern as the site and surrounding area currently experiences problems with car parking.
32. With this in mind we would be keen to work closely with the appropriate staff at the Trust to develop a realistic and meaningful travel plan and to encourage the use of sustainable modes of transport as an alternative to the private car where possible. This would ideally involve the introduction of appropriate infrastructure on the site. We would also like to understand the details of the various transport initiatives proposed as part of the changes including the shuttle bus service and car sharing scheme. The Trust has highlighted a potential planning application to increase car parking capacity at the North Tees site, and this should be progressed as a priority. If this cannot be brought forward to coincide with the transfer of services, then temporary solutions should be investigated.
33. It would also be appropriate to keep under review the facilities available for families, carers and other visitors at the North Tees site, given the increase in numbers that will ensue from these proposals."
Members agreed the above as Stockton's Response to Consultation on Reconfiguration of Critical Care and Emergency Medicine.